Differences in intestinal microbiota profiling after upper and lower gastrointestinal surgery.

BACKGROUND: We aimed to investigate the long-term effects of metabolic profiles and microbiota status in patients after upper gastrointestinal (GI) surgery and lower GI surgery and compared them with a control group. METHODS: In this cross-sectional study, we analyzed the occurrence of metabolic syndrome (MS) in 10 patients who underwent curative total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) anastomosis, 11 patients who underwent curative partial colectomy with right hemicolectomy (RH), and 33 age- and sex-matched controls. Fecal samples were also analyzed by a next-generation sequencing method. RESULTS: Compared with the control group, the occurrence of MS was significantly lower among patients who underwent total gastrectomy with RYEJ than the controls over the long-term follow-up (>8 years; p < 0.05). Patients who received RH only had a trend of higher serum fasting glucose (p = 0.10). The diversity of the gut microbiota significantly decreased after RH in comparison with the control group and RYEJ group, respectively (p < 0.05). Principal component analysis revealed significant differences between the control, RYEJ, and RH groups (p < 0.001). At the genus level, the ratio of Prevotella to Bacteroides (P/B) was significantly higher in the RYEJ group than in the control group, whereas the P/B ratio was significantly lower in the RH group than in the control group (p < 0.05). CONCLUSION: Early gastric cancer patients who received total gastrectomy with RYEJ had a lower occurrence of MS than the controls, while early colorectal cancer patients who received RH were associated with a higher serum fasting glucose than the controls during long-term follow-up. In parallel with the metabolic differences, the P/B ratio was also significantly altered in patients after upper and lower GI surgery.

Comparison of the efficiency of two different proton pump inhibitor formula in treatment of patients with atypical gastroesophageal reflux disease: a prospective randomized study.

BACKGROUND AND AIM: The prospective, open-label, randomized study aims to compare the efficacy of lansoprazole, a fast orally disintegrating proton pump inhibitor (PPI), and dexlansoprazole, a dual delayed release PPI, in patients with atypical symptoms of gastroesophageal reflux disease (GERD). METHODS: Patients with atypical GERD symptoms with a total reflux symptom index score > 10 were eligible for enrollment. From February 2018 to December 2019, 232 subjects were randomly assigned (1:1 ratio) to receive oral lansoprazole, Takepron OD 30 mg, once daily before breakfast or oral dexlansoprazole, Dexilant 60 mg, once daily before breakfast for 8 weeks. The primary end-point is to compare the symptoms response rate after an 8-week PPI therapy between the two groups. RESULTS: There were 232 study subjects enrolling in this study. After the 8-week PPI therapy, dexlansoprazole-treated group had a significantly higher response rate than lansoprazole-treated group in cough (76.5% vs 38.0%) and globus (69.7% vs 30.8%) (P all < 0.05 by intention-to-treat). Multivariate logistic regression analysis showed that the use of dexlansoprazole, presence of dyslipidemia, and typical GERD symptoms (acid reflux and heartburn) were predictors for symptom response for cough; the use of dexlansoprazole and presence of erosive esophagitis were predictors for symptom response for globus (P all < 0.05). No predictor for therapy response to hoarseness was noted. CONCLUSIONS: There is a higher response rate for cough and globus symptoms in patients with atypical GERD after the 8-week PPI therapy with dexlansoprazole rather than lansoprazole.

Predictors of stent occlusion in patients with unresectable pancreatic cancer after biliary metal stents.

BACKGROUND: Self-expandable metal stents (SEMS) are a widely accepted biliary endoprosthesis for patients with unresectable malignant biliary obstruction. Here, we identified predictors for the occlusion of SEMS in unresectable pancreatic cancer patients with biliary tract obstruction. METHODS: Patients with a distal malignant biliary obstruction caused by unresectable pancreatic cancer who received partially covered SEMS (PC-SEMS) placement for the first time between January 2003 and January 2016 were retrospectively enrolled for analysis. The rates of PC-SEMS occlusion were evaluated. The possible predictors of PC-SEMS occlusion were analyzed using Cox regression analysis. RESULTS: In total, 120 patients who received PC-SEMS for unresectable pancreatic cancer were identified. The rate of PC-SEMS occlusion was 37%. The median time to occlusion of PC-SEMS was 359 days. The major causes of occlusion included biliary sludge (61%) and tumor ingrowth (30%). Cox multivariate regression analysis revealed that inadequate alkaline phosphatase/gamma-glutamyl transferase decline (defined by a decrease of <50% within 2 wk after PC-SEMS placement) was the only independent predictor of stent occlusion (hazard ratio, 2.86; 95% CI, 1.28-6.25; p = 0.01) CONCLUSION:: Inadequate alkaline phosphatase/gamma-glutamyl transferase decline is a predictor of occlusion of first-time PC-SEMS placement in unresectable pancreatic cancer patients with biliary tract obstruction.

The long term microbiota and metabolic status in patients with colorectal cancer after curative colon surgery.

Whether there are subsequent changes of metabolic profiles and microbiota status after partial colectomy remains unknown. We evaluated and compared long-term effects of microbiota status and metabolic profiles in early colorectal cancer (CRC) patients after curative colectomy to the controls. In this cross-sectional study, we analyzed metabolic syndrome occurrence in 165 patients after curative partial colectomy with right hemicolectomy (RH) or low anterior resection (LAR) and 333 age-sex matched controls. Fecal samples from some of those with RH, LAR, and controls were analyzed by next-generation sequencing method. The occurrences of metabolic syndrome were significantly higher in patients after RH, but not LAR, when compared with the controls over the long term (> 5 years) follow-up (P = 0.020). Compared with control group, RH group showed lower bacterial diversity (P = 0.007), whereas LAR group showed significantly higher bacterial diversity at the genera level (P = 0.016). Compared with the control group, the principal component analysis revealed significant differences in bacterial genera abundance after RH and LAR (P < 0.001). Furthermore, the Firmicutes to Bacteroidetes ratio was significantly lower in the RH group than the control group (22.0% versus 49.4%, P < 0.05). In conclusion, early CRC patients after RH but not LAR were associated with a higher occurrence of metabolic syndrome than the controls during long-term follow-up. In parallel with metabolic change, patients with RH showed dysbiosis with a tendency to decreased richness and a significant decrease in the diversity of gut microbiota.

Risk factors for upper gastrointestinal bleeding among aspirin users: An old issue with new findings from a population-based cohort study.

BACKGROUND/PURPOSE: We aimed to identify the risk factors of first-time occurrence of non-variceal upper gastrointestinal bleeding (UGIB) among aspirin users after adjusting for confounding factors like age, gender, underlying co-morbidities, and medications. METHODS: Using the National Health Insurance Research Database of Taiwan and matching age, gender, underlying co-morbidities and enrollment time by propensity score, 11105 aspirin users and 11105 controls were identified for comparison from a cohort dataset of 1,000,000 randomly sampled subjects. Cox proportional hazard regression models were used to identify independent risk factors for first-time occurrence of non-variceal UGIB in the study cohort and in the aspirin users after adjusting for age, gender, underlying co-morbidities, and medications (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase-2 [COX-2] inhibitors, steroids, thienopyridines, selective serotonin reuptake inhibitors, warfarin, and dipyridamole). RESULTS: By Cox proportional hazard regression analysis, aspirin use increased the risk of first-time occurrence of UGIB (hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.28-1.72). Age, male gender, Helicobacter pylori (H. pylori)infection, diabetes, chronic kidney disease (CKD), cirrhosis, history of uncomplicated peptic ulcer disease (PUD), and use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines were independent risk factors for UGIB among aspirin users. CONCLUSION: In addition to age, male gender, H. pylori infection, and concomitant use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines, underlying co-morbidities including diabetes, CKD, cirrhosis, history of PUD are also important risk factors for first-time occurrence of non-variceal UGIB in aspirin users.

The long term effect of metabolic profile and microbiota status in early gastric cancer patients after subtotal gastrectomy.

Long term effects of subtotal gastrectomy on gut microbiota modifications with subsequent metabolic profiles are limited. We aimed to investigate and compare long-term effects of metabolic profiles and microbiota status in early gastric cancer patients post curative subtotal gastrectomy to the controls. In this cross-sectional study, we analyzed type II diabetes mellitus and metabolic syndrome occurrence in two groups: 111 patients after curative subtotal gastrectomy with Billroth II (BII) anastomosis and Roux-en-Y gastrojejuno (RYGJ) anastomosis and 344 age-sex matched controls. Fecal samples from those with BII, RYGJ, and controls were analyzed by next-generation sequencing method. Metabolic syndrome and type II diabetes mellitus occurrences were significantly lower in patients after subtotal gastrectomy with RYGJ than in controls over the long term (> 8 years) follow-up (P < 0.05). The richness and diversity of gut microbiota significantly increased after subtotal gastrectomy with RYGJ (P < 0.05). Compared with the control group, the principal component analysis revealed significant differences in bacterial genera abundance after subtotal gastrectomy with BII and RYGJ (P < 0.001). Genera of Oscillospira, Prevotella, Coprococcus, Veillonella, Clostridium, Desulfovibrio, Anaerosinus, Slackia, Oxalobacter, Victivallis, Butyrivibrio, Sporobacter, and Campylobacter shared more abundant roles both in the RYGJ group and BII groups. Early gastric cancer patients after subtotal gastrectomy with RYGJ had a lower occurrence of metabolic syndrome and type II diabetes mellitus than the controls during long term follow-up. In parallel with the metabolic improvements, gut microbial richness and diversity also significantly increased after subtotal gastrectomy with RYGJ.

The factors associated with negative colonoscopy in screening subjects with positive immunochemical stool occult blood test outcomes.

BACKGROUND: The immunochemical fecal occult blood test (iFOBT) is an alternative method to colonoscopy that can be used for colorectal cancer (CRC) screening. If the iFOBT result is positive, a colonoscopy is recommended. In this retrospective study, we identify factors associated with negative colonoscopy and positive iFOBT results obtained during CRC screening. METHODS: We collected data for subjects who received a colonoscopy at Taipei Veterans General Hospital after receiving a positive iFOBT result during CRC screening from January 2015 to December 2015. Subjects' baseline data, medications, and co-morbidities as well as colonoscopy and histological findings were recorded. A negative colonoscopy result was defined as no detection of any colorectal neoplasia including non-advanced adenoma, advanced adenoma, and adenocarciona. Multivariate logistic regression analysis was conducted to identify the associated factors in screening subjects with positive iFOBT but negative colonoscopy results. RESULTS: 559 (46.3%) out of 1207 eligible study subjects received a colonoscopy with a negative result. Multivariate logistic regression analysis revealed that the use of antiplatelets [odds ratio (OR) = 0.654; 95% confidence interval (CI), 0.434-0.986], occurrence of hemorrhoid (OR = 0.595; 95% CI, 0.460-0.768), and the existence of colitis/ulcer (OR = 0.358; 95% CI, 0.162-0.789) were independent factors associated with negative colonoscopy but positive iFOBT results during CRC screening. The colon clean level, underlying diseases of gastrointestinal bleeding tendency (e.g., chronic kidney disease, cirrhosis), and the use of anticoagulant or nonsteroidal anti-inflammatory agents were not associated with negative colonoscopy and positive iFOBT results. CONCLUSION: The use of antiplatelet agents and the presence of hemorrhoids and colitis/ulcers were factors associated with negative colonoscopy and positive iFOBT results.

Risk factors of the peptic ulcer bleeding in aging uremia patients under regular hemodialysis.

BACKGROUND: Previous studies have shown that uremia patients under hemodialysis (HD) have a significantly higher occurrence of peptic ulcer bleeding (PUB) than healthy controls and that elderly patients remain at high risk of peptic ulcer disease (PUD) and PUB. Here we aimed to identify the risk factors for PUB in aging (≥65-years-old) uremic patients under regular HD. METHODS: Using data from the National Health Insurance Research Database of Taiwan, we compared 18,252 aging regular HD patients and 17,883 age-, gender-, and medication-matched patients without kidney disease (control group). The log-rank test was performed to analyze the differences in accumulated hazard of PUB between the two groups. Cox proportional hazard regressions were performed to evaluate independent risk factors for PUB between the two groups and identify risk factors of PUB in aging HD patients. RESULTS: In a 7-year follow-up, aging HD patients had significantly higher incidences of PUB than the matched controls (p < 0.001 by the log-rank test). By Cox proportional hazard regression analysis, HD (hazard ratio [HR] = 4.61; 95% confidence intervals [CI] 4.03-5.27) was independently associated with increased risk of PUB. Age, diabetes mellitus (DM), history of uncomplicated PUD, cirrhosis, and use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids were risk factors for PUB in aging HD patients. CONCLUSION: Aging HD patients are associated with higher risk of PUB. The use of NSAIDs and corticosteroids and co-morbidities including DM, history of uncomplicated PUD, and cirrhosis were identified as risk factors for PUB in these patients.

Risk Factors for Upper Gastrointestinal Bleeding in Patients Taking Selective COX-2 Inhibitors: A Nationwide Population-Based Cohort Study.

Objective: Cyclooxygenase-2 inhibitors (coxibs) are associated with less upper gastrointestinal bleeding (UGIB) than traditional nonsteroidal anti-inflammatory drugs (tNSAIDs). However, they also increase the risk of UGIB in high-risk patients. We aimed to identify the risk factors of UGIB in coxibs users. Design: Retrospective cohort study. Setting: 2000-2010 National Health Insurance Research Database of Taiwan. Subjects: Patients taking coxibs as the study group and patients not taking any coxibs as controls. Methods: After age, gender, and comorbidity matching by propensity score, 12,145 coxibs users and 12,145 matched controls were extracted for analysis. The primary end point was the occurrence of UGIB. Cox multivariate proportional hazard regression models were used to determine the risk factors for UGIB among all the enrollees and coxibs users. Results: During a mean follow-up of three years, coxibs users had significantly higher incidence of UGIB than matched controls (P < 0.001, log-rank test). Cox regression analysis showed that coxibs increased risk of UGIB in all participants (hazard ratio = 1.37, 95% confidence interval = 1.19-1.55, P < 0.001). Independent risk factors for UGIB among coxibs users were age, male gender, diabetes, chronic renal disease, cirrhosis, history of peptic ulcer disease, PU bleeding (PUB), Helicobacter pylori (H. pylori) infection, and concomitant use of tNSAIDs, acetylsalicylic acid, or thienopyridines. Conclusions: Among coxibs users, H. pylori infection and history of PUB were especially important risk factors for UGIB. Further studies are needed to determine whether proton pump inhibitors might play a protective role in these at-risk patients.

Cholecystectomy decreased the recurrent cholangitis after clearance of bile duct stones by ERCP in patients with gallstone-related cholangitis.

BACKGROUND: This study assessed whether cholecystectomy can decrease recurrent cholangitis and all-cause mortality in patients who received endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and successful clearance of bile duct (BD) stones after gallstone-related cholangitis. METHODS: We analyzed data from the National Health Insurance research database of Taiwan. Patients who had gallstone-related cholangitis and underwent successful endoscopic clearance of BD stones were eligible for enrollment. This population-based, propensity score (PS)-matched cohort study involved 2 cohorts; (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as the study group; and (2) those who had no cholecystectomy after ERCP with BD stone clearance as the control group. The primary endpoint was recurrent cholangitis, and the secondary endpoint was all-cause mortality. RESULTS: During a mean 5.7-year follow-up, the incidence rates of recurrent cholangitis were 20.47 per 1000 person-years in the cholecystectomy cohort, and 34.60 per 1000 person-years in the PS-matched control cohort. The risk of recurrent cholangitis was significantly lower in the cholecystectomy cohort than in the control cohort (HR, 0.62; 95% confidence interval [CI], 0.45-0.87; P = 0.006). The HR for all cause mortality among the cholecystectomy cohort was 0.70 (95% CI, 0.54-0.90; P = 0.006) compared with the control cohort. CONCLUSION: Cholecystectomy decreased the recurrent cholangitis and all-cause mortality in patients with endoscopic sphincterotomy and successful clearance of BD stones after gallstone-related cholangitis.

Cholecystectomy Reduces Recurrent Pancreatitis and Improves Survival After Endoscopic Sphincterotomy.

BACKGROUND: The aim of this study was to assess whether cholecystectomy can decrease the recurrent pancreatitis in the elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) and successful clearance of bile duct (BD) stones after gallstone-related acute pancreatitis. METHODS: We analyzed data from National Health Insurance Research Database of Taiwan. Elderly patients (age ≧70 years old) who had gallstone-related acute pancreatitis and underwent successful EST with BD stones clearance were eligible for enrollment. This nationwide, population-based, propensity score (PS)-matched cohort study involved two cohorts: (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as study group and (2) those who adopted wait-and-see strategy (without cholecystectomy) after ERCP with BD stone clearance as control group. The primary and secondary endpoints were recurrent acute pancreatitis and all-cause mortality, respectively. RESULTS: During the study period, a total of 670 elderly patients (male 291, female 379) with a mean age of 79.1 was enrolled for analysis after PS matching. The incidence rate of recurrent acute pancreatitis was 12.39 per 1000 person-years in the cholecystectomy cohort and 23.94 per 1000 person-years in the PS-matched control cohort. The risk of recurrent acute pancreatitis was significantly lower in the cholecystectomy cohort (HR, 0.56; 95 % confidence interval [CI], 0.34-0.91; P = 0.021). The HR for all-cause mortality among the cholecystectomy cohort was 0.75 (95 % CI, 0.59-0.95; P = 0.016) compared with the control cohort. CONCLUSIONS: Cholecystectomy decreased the subsequent recurrent acute pancreatitis and the all-cause mortality in elderly patients with EST and clearance of BD stones after gallstone-related acute pancreatitis.

Use of SSRI, But Not SNRI, Increased Upper and Lower Gastrointestinal Bleeding: A Nationwide Population-Based Cohort Study in Taiwan.

Selective serotonin receptor inhibitor (SSRI) and serotonin-noradrenaline reuptake inhibitor (SNRI) users have been reported to have an increased risk of upper gastrointestinal bleeding (UGIB), but their association with lower gastrointestinal bleeding (LGIB) is less studied. This study aimed to analyze the incidence of UGIB and LGIB among SSRI users, SNRI users, and controls.Using the National Health Insurance Research Database of Taiwan, 9753 subjects who were taking serotonin reuptake inhibitors (8809 with SSRIs, and 944 with SNRIs), and 39,012 age, sex, and enrollment time-matched controls were enrolled at a 1:4 ratio. The log-rank test was used to analyze differences in the cumulative hazard of UGIB and LGIB between groups. Cox proportional hazard regression analysis was used to evaluate the independent risk factors for UGIB and LGIB.During the 10-year follow-up period from 2000 to 2010, SSRI users, but not SNRI users, had significantly higher incidences of UGIB and LGIB than the controls (P < 0.001; log-rank test). The use of SSRIs, but not SNRIs, was independently associated with an increased risk of UGIB (hazard ratio [HR]:1.97; 95% confidence interval [CI]: 1.67-2.31) and LGIB (HR: 2.96, 95% CI: 2.46-3.57) after adjusting for age, sex, underlying comorbidities, and medications.The long-term use of SSRIs significantly increased the risk of UGIB and LGIB, and caused more LGIB than UGIB in the general population after adjusting for possible confounding factors, but the association between SNRIs and GIB is insignificant. Further prospective studies are needed to clarify this important issue.