Endoscopic Sphincterotomy for Gallbladder Muddy Stones or Sludge in Patients With Papillary Disease: A Retrospective Study.

BACKGROUND: The formation of gallbladder stones is associated with dysfunctional contraction and duodenal papilla diseases. However, endoscopic sphincterotomy can improve the contraction of the gallbladder and resolve duodenal papilla disease. AIM: The aim of the study was to assess the feasibility and effectiveness of endoscopic sphincterotomy in the treatment of muddy stones or sludge in the gallbladder during papillary disease. METHODS: The clinical data of 53 patients with gallbladder muddy stones or sludge undergoing endoscopic sphincterotomy were retrospectively analyzed. RESULTS: A total of 53 patients received successful endoscopic sphincterotomy with no serious complications. Sphincterotomy did not significantly lower resting gallbladder volume from 63.2±10.8 to 50.1±5.9 mL (P>0.05), but significantly increased gallbladder ejection fraction from 0.41±0.13 to 0.63±0.16 (P<0.01), as measured by the lipoid food test. The static liver and gallbladder imaging examination also showed an increase in gallbladder ejection fraction from 0.45±0.08 to 0.68±0.11 (P<0.01). In addition, the choledochus pressure reduced from 21.9±4.0 to 15.6±2.5 mm Hg, and the gallbladder muddy stones or sludge disappeared after endoscopic sphincterotomy. At the end of the follow-up period, there was no relapse of sludge or muddy stones in the gallbladder. CONCLUSIONS: The formation of gallbladder muddy stones or sludge is associated with papilla disease. Endoscopic sphincterotomy can resolve papilla disease, decrease gallbladder bile stasis, improve gallbladder evacuation, and prevent the formation of gallbladder stones.

The modified pancreatic stent system for prevention of post-ERCP pancreatitis: a case-control study.

BACKGROUND: Prophylactic pancreatic stents after endoscopic retrograde cholangiopancreatography (ERCP) can help prevent post-ERCP pancreatitis. However most of the pancreatic stents need to be removed by another ERCP. The aim of this observational study was to investigate the feasibility and effectiveness of the modified pancreatic stent system for prevention of post-ERCP pancreatitis. METHODS: From November 2013 to November 2015, a total of 230 patients who had prophylactic pancreatic stent placed for prevention of post-ERCP pancreatitis at a single institution were identified and stratified. In this case-control design, 150 patients received an ordinary pancreatic stent, and 80 patients received the modified pancreatic stent. The main outcome measures were the difficulty level and complications of pancreatic stent placement and extraction between the two groups. RESULTS: In ordinary group, the average time of pancreatic stent and nasal biliary drainage placement was 3.5 ± 0.6 min. There were 13 cases of stent proximal migration (8.7%), 20 cases of stent spontaneous abscission (13.3%), 5 cases of acute pancreatitis (3.3%) (2 cases for stent abscission) and 7 cases of hyperamylasemia (4.7%) after ERCP. One hundred thirty patients received extra duodenoscope (86.7%) to remove the stent, and 4 cases had acute pancreatitis and 5 patients had hyperamylasemia after removing the proximal migratory stents. In modified group, the average time of pancreatic stent system placement was 4.9 ± 0.7 min, but there was only one case of stent abscission (1.3%), 2 cases of acute pancreatitis (2.5%) and 3 cases of hyperamylasemia (3.8%). The new pancreatic stents were removed directly under x-ray without complication. CONCLUSIONS: The modified pancreatic stent system has the same effect of preventing post-ERCP pancreatitis, lower rate of stents proximal migration and spontaneous abscission, and the advantage of easier removed compared with ordinary pancreatic stent.

Choledochoscopic high-frequency needle-knife electrotomy for treatment of anastomotic strictures after Roux-en-Y hepaticojejunostomy.

BACKGROUND: Anastomotic stricture is a complex and substantial complication following Roux-en-Y hepaticojejunostomy. Initially, endoscopic and percutaneous approaches are often attempted, but the gold standard remains surgical biliary reconstruction, especially for refractory stricture. However, this solution leaves much room for improvement, due to the challenging nature of the biliary reconstruction procedure, in which anastomotic stricture may still occur. AIMS: To investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy as an intervention in the treatment of anastomotic strictures following Roux-en-Y hepaticojejunostomy. METHODS: From February 2010 to October 2014, clinical data was collected and retrospectively compared for patients who underwent balloon dilation or/and choledochoscopic high-frequency needle-knife electrotomy for the treatment of anastomotic strictures after Roux-en-Y hepaticojejunostomy. RESULTS: A total of 38 patients underwent successful choledochoscopic treatment and all the anastomotic strictures were removed successfully, 19 of which were treated with electrotomy, 7 with balloon dilation, and 12 with both electrotomy and balloon dilation. Among these groups,the average operating times were 6.9 ± 2.4 min,10.1 ± 6.8 min, and 20.2 ± 13.5 min, respectively. The average stent supporting times were 6.3 ± 0.7 months, 6.5 ± 0.6 months, and 6.1 ± 0.4 respectively. The mean follow-up after stent removal was 42.1 ± 27.4 months, and in 26.3 % (5/19), 28.5 % (2/7) and 16.7 % (2/12) of cases, recurrent anastomotic stricture occurred. Of these 9 total patients with recurrent anastomotic, two patients were successfully rescued by full-covered self-expanding removable metal stents and 7 patients by electrotomy combined with balloon dilation. CONCLUSIONS: Choledochoscopic high-frequency needle-knife electrotomy is both feasible and safe in the treatment of anastomotic stricture after Roux-en-Y hepaticojejunostomy, with a similar long-term outcome to balloon dilation in treating anastomotic stricture after Roux-en-Y hepaticojejunostomy. A combination of choledochoscopic electrotomy concurrent with balloon dilation should be recommended based on the low rate of recurrence.

Common bile duct injury by fibrin glue: report of a rare complication.

Fibrin glue is widely used in clinical practice and plays an important role in reducing postoperative complications. We report a case of a 65-year-old man, whose common bile duct was injured by fibrin glue, with a history of failed laparoscopic cholecystectomy and open operation for uncontrolled laparoscopic bleeding. In view of the persistent liver dysfunction, xanthochromia and skin itching, the patient was admitted to us for further management. Ultrasound, computed tomography, and magnetic resonance cholangiopancreatography (MRCP) revealed multiple stones in the common bile duct, and liver function tests confirmed the presence of obstructive jaundice and liver damage. Endoscopic retrograde cholangiopancreatography was unsuccessfully performed to remove choledocholithiasis, but a small amount of tissue was removed and pathologically confirmed as calcified biliary mucosa. This was followed by open surgery for suspicious cholangiocarcinoma. There was no evidence of cholangiocarcinoma, but the common bile duct wall had a defect of 8 mm × 10 mm at Calot's triangle. A hard, grid-like foreign body was removed, which proved to be solid fibrin glue. Subsequently, the residual choledocholithiasis was removed by a choledochoscopic procedure, and the common bile duct deletion was repaired by liver round ligament with T-tube drainage. Six months later, endoscopy was performed through the T-tube fistula and showed a well-repaired bile duct wall. Eight months later, MRCP confirmed no bile duct stenosis. A review of reported cases showed that fibrin glue is widely used in surgery, but it can also cause organ damage. Its mechanism may be related to discharge reactions.

Choledochoscopic high-frequency needle-knife electrotomy as an effective treatment for intrahepatic biliary strictures.

BACKGROUND AND AIM: Hepatolithiasis is associated with the presence of intrahepatic biliary strictures, and balloon dilatation is the main approach. However, this method is difficult to implement if the bile duct distal to the stricture is blocked by stones. Therefore, alternative methods need to be explored to effectively treat hepatolithiasis. The aim of this study is to investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy for the treatment of intrahepatic biliary strictures. METHODS: Clinical data of 58 patients suffering from intrahepatic bile duct strictures from January 2011 to January 2013 were retrospectively analyzed. Choledochoscopic electrotomy was used to resolve the strictures. RESULTS: One hundred thirty-four sites of intrahepatic bile duct strictures were discovered. The average operating time of electrotomy is 5.6 min (range, 1 ∼ 15 min). Structured bile duct tissue bleeding occurred in eight sites (8/134, 6.0%) but were resolved by endoscopic high-frequency electric cautery. After the operations, 14 cases of cholangitis (14/58, 24.1%), three cases of delayed hemobilia, one case of liver abscess (1/58, 1.7%), and seven cases of stenting exodus (7/58, 12.1%) were observed despite conservative treatment and stenting reset. The average supporting time was 7.0 months (6 ∼ 9 months). No abnormal bile duct structure or presence of stone was found according to choledochoscopy. The follow-up period ranged from 12 to 48 months. Hepatolithiasis recurred in five (5/58, 8.6%) patients, and the cumulative recurrent probability of intrahepatic bile duct stricture was 5.2% (7/134). CONCLUSIONS: Choledochoscopic high-frequency needle-knife electrotomy could be considered as a simple, safe, and effective complementary approach for treating intrahepatic biliary strictures.

Multiple resistance-activating substances produced by Humicola phialophoroides isolated from soil for control of Phytophthora blight of pepper.

BACKGROUND: Microorganisms capable of utilizing vegetable tissues for multiplication in soil were isolated, cultivated in liquid medium prepared from the same vegetable tissues, and tested for ability to activate resistance in pepper leaves against Phytophthora blight caused by Phytophthora capsici. RESULTS: Among the 121 microorganisms isolated, a fungus Humicola phialophoroides showed distinct ability to produce substances capable of activating resistance. The resistance-activating substances produced by H. phialophoroides were mostly retained in the mycelium, and were readily extracted from the mycelium powder with polar solvents. The extract was not inhibitory to zoospore germination or germ tube growth of P. capsici. In pepper leaves, the extract took only about 12 h to activate resistance against P. capsici. After activation, washing treated leaf surface with water did not have much effect on the resistance expression. In addition to being able to move from the upper leaf surface to lower leaf surface, the resistance-activating substances were capable of moving 5 mm acropetally and 10 mm basipetally in pepper leaves, Chromatography of the extract on silica gel column suggests that there are probably more than three components in the extract with resistance-activating ability. The resistance-activating activity of the mycelium extract was not affected by treatment with either cation or anion exchange resins, indicating that none of the active components have positive or negative charges on their molecules. CONCLUSION: Results show that H. phialophoroides is capable of producing multiple resistance-activating substances which are mostly retained in the mycelium. The study also indicates that none of the active components have positive or negative charges on their molecules.

Biliary casts after liver transplantation: morphology and biochemical analysis.

AIM: To investigate the pathogenesis of biliary casts after liver transplantation relative to their morphology and biochemical markers. METHODS: The microstructure of biliary casts was assessed using scanning electron microscopy and Hematoxylin and eosin staining assessed their histology. The expression levels of CD3, CD5, CD34, CD68 and CD79a in these biliary casts were evaluated immunohistochemically. RESULTS: Biliary casts differed widely in their microstructure, with some containing blood vessels positive for CD34 and collagen fibers with positive Masson staining. Large numbers of neutrophils and other inflammatory cells were present, but only on the edge of the biliary casts; although the boundaries were clear without crossover. None of the biliary casts contained T-lymphocytes, B-lymphocytes, macrophages and other inflammatory cells. CONCLUSION: The microcostructure of biliary casts differed. Bacteria and acute rejection are not clearly related to their formation.

Clinical analysis and significance of cholangiography for biliary cast/stone after orthotopic liver transplantation.

Cholangiography is an important method for the diagnosis of biliary complications after orthotopic liver transplantation. The cholangiography after orthotopic liver transplantation presents special challenges, especially in patients with biliary cast/stone and biliary stenosis. We described the T-tube cholangiography combined therapeutic fibro-choledochoscopy for the diagnosis and treatment of biliary cast following after orthotopic liver transplantation. Fourteen patients who developed biliary cast/stone after liver transplantation were analyzed retrospectively. The complications were divided into three temporal stages, early, medium, and late. Hepatic functions and the characteristics of the bile duct were observed by T-tube cholangiography and endoscopy. The biliary cast after liver transplantation was divided into three categories: Solitary, multiple, and columnar. Three months after liver transplantation, bile ducts appeared fuzzy by T-tube cholangiography, but no evidence of biliary cast was found. The bile duct was feculent with flocculation during the middle stage 3-6 months after liver transplantation. At six months after transplantation, bile ducts (especially intrahepatic bile ducts) were distended; cholangiectasis was obvious with biliary cast. The intrahepatic bile duct stricture was observed on occasion by T-tube cholangiography and the intrahepatic bile duct could be thin and distended, and resembled withered branches or strings of beads. The intrahepatic bile ducts even disappeared at this stage; hepatic functions were usually unacceptable and the icterus gradually aggravated. Four cases were diagnosed earlier according to the categories of stone and stage. Curative therapy was performed promptly and the clinical outcome was acceptable. Biliary tracts of the transplanted livers could be observed by T-tube channels and biliary complications were treated effectively by therapeutic fibro-choledochoscopy. It is necessary to combine T-tube cholangiography with fibro-choledochoscopy for the diagnosis and treatment of biliary complications after orthotopic liver transplantation.

Characterization of a fungistatic substance produced by Aspergillus flavus isolated from soil and its significance in nature.

A fungus capable of using vegetable tissues for multiplication in soil was isolated and identified as Aspergillus flavus based on morphological characteristics and sequence similarity of ITS and 28S. When grown in liquid medium prepared from the same vegetable tissues used in soil amendment, the isolate of A. flavus produced a substance capable of preventing disease development of black leaf spot of mustard cabbage caused by Alternaria brassicicola and inhibiting the germination of A. brassicicola conidia. The inhibitory substance was fungistatic, and was very stable under high temperature and high or low pH value. It was soluble in ethanol or methanol, moderately soluble in water, and insoluble in acetone, ethyl acetate or ether. The inhibitor is not a protein and has no charges on its molecule. This is the first discovery of the production of a fungistatic substance by this deleterious fungus. Results from this study suggest the possession of a strong competitive saprophytic ability by A. flavus, which in turn may explain the widespread occurrence of this fungus in soils. Production of a fungistatic substance when A. flavus was grown in medium prepared from vegetable tissues suggests the importance of antibiotic production in its competitive saprophytic colonization of organic matters in soils.

Development of artificial conidia for ecological studies of Rhizoctonia solani in soil.

Artificial conidia of Rhizoctonia solani were developed by releasing protoplasts from young mycelia with lytic enzymes and by inducing cell wall formation in stabilizer solution. Conidia produced in this way were spherical with sizes ranging from 10 to 20µm in diameter. Artificial conidia were sensitive to soil fungistasis. Young hyphae originated from artificial conidia were also sensitive to fungistasis and mycolysis in soils. These results demonstrate that the previously reported insensitivity of R. solani to fungistasis and mycolysis in soils is due to special ability of propagules used rather than the inherited nature of the organism. Germination rates of artificial conidia on soils were inversely correlated with the amount of fungicide Flutolanil added. When germination of artificial conidia was used to detect suppressive soils, 3 out of 30 soil samples collected from different parts of Taiwan were suppressive to R. solani and all these suppressive soils were low in pH. Using artificial conidia for assay of fungicide activity in soil and detection of suppressive soils has the advantages of being fast and precise in comparison with relative hyphal growth. However, preparation of artificial conidia at this stage is tedious and time-consuming.

Activity and characterization of secondary metabolites produced by a new microorganism for control of plant diseases.

Microorganisms capable of utilizing vegetable tissues for growth in soils were isolated and their vegetable broth cultures were individually sprayed directly on leaves to test their ability to control Phytophthora blight of bell pepper caused by Phytophthora capsici. Liquid culture of Streptomyces strain TKA-5, a previously undescribed species obtained in this study, displayed several desirable disease control characteristics in nature, including high potency, long lasting and ability to control also black leaf spot of spoon cabbage caused by Alternaria brassicicolca. The extract was fungicidal to P. capsici but fungistatic to A. brassicicola. It was stable at high temperature and high pH. However, after exposure to pH 2 for 24h, the extract was no longer inhibitory to P. capsici although it was still strongly inhibitory to A. brassicicola. After treatment with cation or anion exchange resins, the extract lost its inhibitory effect against P. capsici but not A. brassicicola. The results suggest that the extract contained two different kinds of inhibitory metabolites, one against P. capsici with both positive and negative charges on its molecule and another against A. brassicicola with no charges on its molecule. The inhibitory metabolites were soluble in ethanol or methanol but not in water, ether or chloroform. They were dialyzable in the membrane tubing with molecular weight cut-off of 10,000, 1000 or 500 but not 100, indicating that the inhibitors have a molecular weight between 500 and 100. Results also showed that both inhibitors are not proteins.

Factors affecting protoplast formation by Rhizoctonia solani.

Novozym 234 was the most frequently used enzyme for production of Rhizoctonia solani protoplasts. Since manufacture of this enzyme was discontinued in the late 1990s, a new procedure was developed by testing lytic enzymes from Sigma and by examining factors affecting protoplast formation. The combination of 20 mg/mL Driselase and 10mg/mL lysing enzyme was effective in releasing protoplasts from R. solani. The optimal condition for enzyme treatment of mycelium was incubation at 37 degrees C for 15 min followed by 34 degrees C for 105 min. The amount of protoplasts produced was positively correlated with growth rate and negatively correlated with mycelial density. Under favorable conditions, R. solani mycelia released 1.68 x 10(6) protoplasts/mL that is comparable with that produced with Novozym 234. Among various media tested, the best solid medium for protoplast regeneration was 1% V-8 juice agar, while the best liquid medium was 10% potato dextrose broth.

Preclinical evaluation of a novel pyrimidopyrimidine for the prevention of nucleoside and nucleobase reversal of antifolate cytotoxicity.

Antifolates have been used to treat cancer for the last 50 years and remain the mainstay of many therapeutic regimes. Nucleoside salvage, which depends on plasma membrane transport, can compromise the activity of antifolates. The cardiovascular drug dipyridamole inhibits nucleoside transport and enhances antifolate cytotoxicity in vitro, but its clinical activity is compromised by binding to the plasma protein alpha(1)-acid glycoprotein (AGP). We report the development of a novel pyrimidopyrimidine analogue of dipyridamole, NU3153, which has equivalent potency to dipyridamole, remains active in the presence of physiologic levels of AGP, inhibits thymidine incorporation into DNA, and prevents thymidine and hypoxanthine rescue from the multitargeted antifolate, pemetrexed. Pharmacokinetic evaluation of NU3153 suggested that a soluble prodrug would improve the in vivo activity. The valine prodrug of NU3153, NU3166, rapidly broke down to NU3153 in vitro and in vivo. Plasma NU3153 concentrations commensurate with rescue inhibition in vitro were maintained for at least 16 hours following administration of NU3166 to mice at 120 mg/kg. However, maximum inhibition of thymidine incorporation into tumors was only 50%, which was insufficient to enhance pemetrexed antitumor activity in vivo. Comparison with the cell-based studies revealed that pemetrexed enhancement requires substantial (> or =90%) and durable inhibition of nucleoside transport. In conclusion, we have developed non-AGP binding nucleoside transport inhibitors. Pharmacologically active concentrations of the inhibitors can be achieved in vivo using prodrug approaches, but greater potency is required to evaluate inhibition of nucleoside rescue as a therapeutic maneuver.

Occurrence of isolates of Phytophthora colocasiae in Taiwan with homothallic behavior and its significance.

Leaf blight and corm rot caused by Phytophthora colocasiae are the most devastating diseases of taro. Oospores of P. colocasiae have not been considered important in the survival in natural soil because the pathogen is heterothallic and there is essentially no chance for the presence of both A1 and A2 mating types in the same host tissue. During our recent survey of the mating type distribution of P. colocasiae in Taiwan seven homothallic isolates of Phytophthora were obtained from diseased taro leaves at Tsu Chi in central Taiwan. These organisms were identified as P. colocasiae based on morphological characteristics, ITS sequence homology and pathogenicity to taro plants. The homothallic isolates of P. colocasiae segregated into A1 and A2 types in addition to the original A1A2 type during asexual reproduction and vegetative growth. The homothallic isolate and the mixture of its A1 and A2 segregants produced abundant oospores in live tissue of taro petioles on or away from soil, indicating the possibility of oospores as a survival structure and the source of genetic variation in certain areas in nature.