Characterization of biliary and duodenal microbiota in patients with primary and recurrent choledocholithiasis.

Purpose: To explore the biliary and duodenal microbiota features associated with the formation and recurrence of choledocholithiasis (CDL). Methods: We prospectively recruited patients with primary (P-CDL, n = 29) and recurrent CDL (R-CDL, n = 27) for endoscopic retrograde cholangiopancreatography (ERCP). Duodenal mucosa (DM), bile and bile duct stones (BDS) samples were collected in P- and R-CDL patients. DM samples were also collected in 8 healthy controls (HC). The microbiota profile analysis was performed with 16S rRNA gene sequencing. Results: Short-course antibiotic application before ERCP showed no significant effects in alpha and beta diversities of the biliary and duodenal microbiota in CDL. Alpha diversity showed no difference between DM and bile samples in CDL. The duodenal microbial richness and diversity was lower in both P- and R-CDL than HC. The biliary microbiota composition showed a high similarity between P- and R-CDL. Fusobacterium and Enterococcus were higher abundant in DM, bile, and BDS samples of R-CDL than P-CDL, as well as Escherichia and Klebsiella in bile samples of R-CDL. The enriched duodenal and biliary bacteria in CDL were closely associated with cholecystectomy, inflammation and liver dysfunction. The bile-associated microbiota of R-CDL expressed enhanced capacity of D-glucuronide and D-glucuronate degradation, implicating an elevated level of ß-glucuronidase probably produced by enriched Escherichia and Klebsiella in bile. Conclusions: The duodenal microbiota was in an imbalance in CDL. The duodenal microbiota was probably the main source of the biliary microbiota and was closely related to CDL formation and recurrence. Enterococcus, Fusobacterium, Escherichia and Klebsiella might contribute to CDL recurrence. Clinical trials: The study was registered at the Chinese Clinical Trial Registry (https://www.chictr.org.cn/index.html, ChiCTR2000033940). Supplementary Information: The online version contains supplementary material available at 10.1007/s13755-023-00267-2.

Analysis of risk factors for post-endoscopic papillectomy bleeding.

BACKGROUND: Endoscopic papillectomy (EP) is an effective treatment for ampullary lesions but technically challenging because of anatomical specificities concerning the high rate of adverse events. Bleeding is one of the most feared complications and can be potentially life-threatening. AIM: To study the risk factors for bleeding after EP are presented with the goal of establishing preventive measures. METHODS: A total of 173 consecutive patients with ampullary lesions undergone EP from January 2006 to October 2020 were enrolled in this study. They were divided into a bleeding group and a non-bleeding group depending on whether postoperative bleeding occurred. Related factors were analyzed by univariate and multivariate logistics regression. RESULTS: Postoperative bleeding was experienced in 33 patients (19.07%). Multivariate analysis also identified intraoperative bleeding (OR: 4.38, 95% CI: 1.87-11.15, p = .001) and endoscopic closure (OR: 0.25, 95% CI: 0.10-0.58, p = .001) as independent factors significantly associated with bleeding after EP. Lesion size (≥3 cm) was shown as an independent factor significantly associated with intraoperative bleeding (OR: 4.25, 95% CI: 1.21-16.44, p = .028). CONCLUSIONS: This retrospective evaluation found that endoscopic closure was associated with reduced risk and intraoperative bleeding with increased risk of bleeding after EP. Lesion size may indirectly influence the risk of postoperative bleeding by increasing the risk of intraoperative bleeding.

Novel endoscopic papillectomy for reducing postoperative adverse events (with videos).

BACKGROUND: Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenoma, and bleeding, perforation, and pancreatitis are the most frequent and critical adverse events that restrict its wider use. There is no standard procedure for endoscopic papillectomy yet. The procedure is relevant to postoperative adverse events. AIM: To reduce the postoperative adverse event rates and improve patients' postoperative condition, we developed a standard novel procedure for endoscopic papillectomy. METHODS: The novel endoscopic papillectomy had two main modifications based on the conventional method: The isolation of bile from pancreatic juice with a bile duct stent and wound surface protection with metal clips and fibrin glue. We performed a single-center retrospective comparison study on the novel and conventional methods to examine the feasibility of the novel method for reducing postoperative adverse events. RESULTS: A total of 76 patients, of whom 23 underwent the novel procedure and 53 underwent the conventional procedure, were retrospectively evaluated in this study. The postoperative bleeding and pancreatitis rates of the novel method were significantly lower than those of the conventional method (0 vs 20.75%, P = 0.028, and 17.4% vs 41.5%, P = 0.042, respectively). After applying the novel method, the most critical adverse event, perforation, was entirely prevented, compared to a prevalence of 5.66% with the conventional method. Several postoperative symptoms, including fever, rapid pulse, and decrease in hemoglobin level, were significantly less frequent in the novel group (P = 0.042, 0.049, and 0.014, respectively). Overall, the total adverse event rate of the novel method was lower (0 vs 24.5%, P = 0.007) than that of the conventional method. CONCLUSION: Patients who underwent the novel procedure had lower postoperative adverse event rates. This study demonstrates the potential efficacy and safety of the novel endoscopic papillectomy in reducing postoperative adverse events.

Clinical Features, Diagnosis, and Treatment Strategies of Gastrointestinal Diaphragm Disease Associated with Nonsteroidal Anti-Inflammatory Drugs.

Background. To demonstrate the clinical features, diagnosis, and treatment of nonsteroidal anti-inflammatory drug- (NSAID-) induced diaphragm disease (DD). Methods. A literature search between January 1973 and August 2015 was undertaken. The clinical data of patients with NSAID-induced DD were recorded and analyzed. Results. 159 patients were included. The ratio of male to female was 1 : 2.3; the mean age was 65 ± 11 years. The most common clinical manifestations were gastrointestinal bleeding and obstruction. 121 (84%) patients took traditional NSAIDs. The durations of NSAIDs use ranged from 2 to 300 months. A majority (59.7%) of DD were seen in the small bowel, were seen secondly in the colon (30.2%), and were mainly located in the ileum (57.9%) and right colon (91.7%), respectively. 80% of patients had multiple diaphragms. 41.5% of small bowel DD were diagnosed preoperatively by capsule endoscopy and/or double-balloon enteroscopy, 52.1% at laparotomy. Nearly 75% of patients underwent surgery, endoscopic balloon dilation was performed in 22 patients, and NSAIDs were withdrawn in 53 patients. Conclusions. NSAID-induced DD is relatively rare. The small bowel is most commonly involved. Preoperative diagnosis of small bowel DD is relatively difficult. Discontinuation of the NSAIDs is recommended, surgical resection is the main treatment presently, and endoscopic balloon dilation should be considered as an alternative therapy.

[Effectiveness and safety of endoscopic ultrasound-guided transgastric or transpapillary drainage in treating pancreatic pseudocyst].

OBJECTIVE: To explore the effectiveness and safety of endoscopic transgastric or transpapillary drainage in treating pancreatic pseudocysts. METHODS: The clinical data of 15 patients with pancreatic pseudocyst who underwent endoscopic ultrasound-guided transgastric or transpapillary drainage in the Chinese PLA General Hospital between June 2004 and February 2013 were retrospectively analyzed. Also, we reviewed the relevant Chinese literature in the China Academic Journal Network Publishing Database (from 1994 to 2012) and VIP China Science and Technology Journal Database (from 1989 to 2012) using the key words "pancreatic pseudocyst and drainage". Five literatures including 103 cases were enrolled. RESULTS: The data of 118 cases undergoing endoscopic drainage, included 94 cases with transgastric approach and 24 with transpapillary approach, entered the final analysis. The success rate was 94.9%, and cysts completely disappeared in 83.9% of the patients. The overall incidence of complications (bleeding, infection, and stent clogging or migration) was 19.5%. One patient lost to follow-up and only one case of recurrence was noted. CONCLUSION: Endoscopic transgastric or transpapillary drainage is safe and effective in treating the pancreatic pseudocysts and therefore can be a preferred therapeutic approach.

[The difference in diagnosis rate of different diagnostic criteria of autoimmune pancreatitis and its major influential factors].

OBJECTIVE: To discuss the difference in diagnostic criteria of autoimmune pancreatitis(AIP) and its major influential factors, so as to provide guidance for AIP diagnosis and treatment. METHODS: The clinical data of 561 cases of chronic pancreatitis admitted to PLA General Hospital from June, 2008 to January, 2013 were retrospectively reviewed and analyzed. Data were extracted and analyzed to summarize the reasons of the differences in AIP diagnosis rate diagnosed by different diagnostic criteria. RESULTS: A total of 34 cases were eligible for the 2006 American HISORt criteria of AIP of whom, 5, 10 and 26 met the criteria of histology, pancreatic imaging findings and increasing serum IgG4 levels, and response to steroids and increasing serum IgG4 levels, respectively. Seven AIP patients met the latter two criteria. Fifteen patients were eligible for the 2008 Asian diagnostic criteria for AIP, of which, 10 met the two necessary imaging findings and 5 met the criteria of pathology of lymphoplasmacytic sclerosing pancreatitis (LPSP) after surgical resection. CONCLUSIONS: AIP is characterized by autoimmune inflammatory process, and is easy to be misdiagnosed as pancreatic cancer or cholangiocarcinoma etc. As a few sets of criteria issued from different countries, the 2008 Asian diagnostic criterion is more suitable with Chinese population. We should pay full attention to the importance of imaging examination of the diagnosis of AIP on the base of the detection of immune parameters, pathological examination and response to steroids.

Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital.

BACKGROUND: The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS: The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS: In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcot's triad (P<0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and 15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS: The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.

Is prophylactic somatostatin effective to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis or hyperamylasemia? A randomized, placebo-controlled pilot trial.

BACKGROUND: Effects of prophylactic somatostatin on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and hyperamylasemia remain inconclusive. This study aimed to examine whether high-dose, long-term continuous infusion of somatostatin can reduce the incidence of PEP and post-ERCP hyperamylasemia. METHODS: This was a randomized, placebo-controlled pilot trial. One hundred and twenty-four patients scheduled for ERCP from December 2008 to May 2010 randomly received one of the following three interventions: pre-ERCP somatostatin (0.5 mg/h for 24 hours, starting 1 hour prior to ERCP; n = 36), post-ERCP somatostatin (0.5 mg/h for 24 hours, starting 1 hour after ERCP; n = 47), or placebo (saline for 24 hours, starting 1 hour prior to ERCP; n = 41). Serum amylase and lipase concentrations were measured 1 to 3 hours prior to ERCP and 6, 24, and 48 hours after ERCP. RESULTS: The three groups did not differ in age, gender, medical history, or ERCP procedure (catheterization using contrast or guidewire, pancreatic duct visualization, procedure time, or procedure type). The rate of PEP was 13.7% (17/124) in the overall study sample and 16.7% (6/36), 10.6% (5/47), and 14.6% (6/41) in the pre-ERCP somatostatin, post-ERCP somatostatin, and placebo groups, respectively (P = 0.715). The rate of post-ERCP hyperamylasemia was 19.4% (7/36), 21.3% (10/47), and 46.3% (19/41) in the pre-ERCP somatostatin, post-ERCP somatostatin, and placebo groups, respectively (P = 0.011). CONCLUSIONS: High-dose, long-term continuous infusion (0.5 mg/h for 24 hours) of somatostatin, performed as either a pre- or post-ERCP, can reduce the incidence of hyperamylasemia, but not PEP.

Gastric body diaphragm-like stricture as a rare complication of nonsteroidal anti-inflammatory drugs.

Increased risk due to nonsteroidal anti-inflammatory drugs (NSAIDs) therapy has been observed in patients. Although diaphragm-like stricture in the small bowel and colon induced by NSAIDs therapy has been rarely reported, gastric body diaphragm-like stricture has not been reported. We describe the first case of gastric body diaphragm-like stricture due to NSAIDs in a 44-year-old male patient who was successfully treated by an endoscopic approach to avoid complicated surgery. This case highlights new insight into the disadvantages of NSAIDs and provides new data for future clinical studies.

[Causes and management of ischemic-type biliary lesion after orthotopic liver transplantation].

OBJECTIVE: To discuss the causes, diagnosis, prophylaxis and treatment of ischemic-type biliary lesions (ITBLs) following orthotopic liver transplantation (OLT). METHODS: A retrospective analysis was performed for 326 OLT patients from January 2002 to January 2009. The post-OLT etiological factors and treatment of ITBL cases were analyzed. RESULTS: ITBL occurred in 23 patients (7.05%). It included intrahepatic biliary lesions (n=9), extrahepatic lesions (n=12) and diffuse extrahepatic and intrahepatic biliary lesions (n=2). Through a COX regression, the risk factors were independently associated with ITBL serious hepatitis as the primary disease (RR: 3.204; P=0.014) and cold donor ischemic time beyond 11.5 hours (RR: 4.895; P=0.000). All ITBL patients underwent drug therapy, endoscopy (n=10), operation (n=6) or re-OLT (n=7). And improvement was found in 17 patients. CONCLUSION: Avoiding too long old ischemic time of donor liver and carefully evaluating the indications of recipients are effective preventive measures of ITBL. It is crucial to select a proper treatment according to the conditions of each individual patient.

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. METHODS: Thirty-six patients with obstructive jaundice underwent the rendezvous technique of PTBD and ERCP after initially unsuccessful ERCP. RESULTS: The procedure of 36 cases were all successful. Sixteen cases underwent PTBD drainage from the bile duct through the right lobe approach and in 20 cases the left lobe approach was used. The one-stage procedure involved in the rendezvous technique of PTBD and ERCP was successful in 23 cases, while the other 13 cases underwent PTBD first and then rendezvous ERCP the next time. The serum total bilirubin 4 days later had decreased by 44.75%, and direct bilirubin had decreased by 45.61%. The main complication was infection of the bile duct. CONCLUSION: Stent implantation using the rendezvous technique of PTBD and ERCP is a new and feasible method to treat obstructive jaundice after initially unsuccessful ERCP. This may be of considerable value in clinical practice.

Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years' experience of 635 cases.

BACKGROUND: Gastric varices (GV) are life-threatening for patients with portal hypertension. Endoscopic injection with butyl cyanoacrylate (BC), the mainstay of the therapy for GV, has been reported to be effective for hemostasis of bleeding varices, but its efficacy in the obliteration of GV and impact on the survival of patients still needs clarification. Here we summarized our experience of 10 years' practice to evaluate the efficacy and safety of endoscopic therapy using BC for GV patients. METHODS: From January 1997 to April 2006, GV cases treated with endoscopic injection using BC were collected. The "sandwich method" and the "modified sandwich method" were used to inject BC intravascularly. Retrograde analysis was made on the data of treatment and follow-up. RESULTS: A total of 635 GV cases treated with endoscopic injection using BC were collected, most of them (90.2%) suffered from post-hepatitis cirrhosis. Emergency hemostasis was achieved in 139 out of 146 sessions (95.2%). Complications occurred in 32 cases (5.2%), including hemorrhage due to early expulsion of tissue glue (3.1%), septicemia (1%) and ectopic thrombosis (0.5%), such as spleen infarction. Endoscopic follow-up in 503 patients showed complete disappearance (76.9%), collapse (17.3%) or remnants (5.8%) of gastric varices. A total of 550 patients were followed up clinically for 3 to 115 months. Of these patients, 44 had recurrent bleeding (8.0%) and 44 died from hepatic failure, recurrent bleeding, hepatic carcinoma or other causes. The longest survival was 115 months, with a median survival of 25 months. Survival rates at 1, 2, 3, 4 and 5 year were 95%, 92%, 90%, 83% and 81%, respectively. CONCLUSIONS: Endoscopic sclerotherapy with BC is effective for the hemostasis of bleeding GV, as well as obliteration of GV which contributes to less rebleeding and better survival. The modified sandwich method may be useful to minimize ectopic embolism, which we speculated to result from excess iodized oil.

Intraductal ultrasonography and endoscopic retrograde cholangiography in diagnosis of extrahepatic bile duct stones: a comparative study.

BACKGROUND: Intraductal ultrasonography (IDUS) is highly accurate in detection of extrahepatic bile duct stones. This study was to compare the accuracy of IDUS and endoscopic retrograde cholangiography (ERC) in the diagnosis of extrahepatic bile duct stones. METHODS: Thirty patients suspected of extrahepatic bile duct stones on B ultrasonography, CT, or MRI were enrolled for study. ERC was performed using a Fujinon duodenoscope (ED-410XT, ED-410Xu), then IDUS was done by inserting a Fujinon microprobe (PL2220-15) through the endoscopic biopsy channel to detect the extrahepatic bile duct. Finally stones in the extrahepatic bile duct were detected and extracted by endoscopic sphincterotomy (EST). RESULTS: Among the 30 patients, 26 were diagnosed as having cholelithiasis accurately through ERC. In one patient the stone detected by ERC was really floccule. Misdiagnosis happened in 2 patients with extrahepatic bile duct stones. So the overall accuracy and sensitivity of ERC in the diagnosis of extrahepatic bile duct stones were 86.7% (26/30) and 92.9% (26/28) respectively. In contrast, IDUS showed the results of diagnosis were in consistent with those of EST stone extraction. Its accuracy and sensitivity in the diagnosis of extrahepatic bile duct stones were 100% (30/30) and 100% (28/28) respectively. CONCLUSION: IDUS which is superior to ERC in diagnosing extrahepatic bile duct stones can avoid the visual error of ERC.