Electromagnetic-guided versus endoscopic-guided postpyloric placement of nasoenteral feeding tubes.

BACKGROUND: For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine.  Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access. OBJECTIVES: To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement. SEARCH METHODS: We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. We contacted the study authors for missing data. SELECTION CRITERIA: We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach. MAIN RESULTS: We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials.  Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence).  Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence). AUTHORS' CONCLUSIONS: We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.

Severe Hypomagnesemia Associated with the Long-term Use of the Potassium-competitive Acid Blocker Vonoprazan.

Hypomagnesemia caused by a proton pump inhibitor (PPI) was first reported in 2006. We herein report a case of hypomagnesemia due to the long-term use of vonoprazan, a potassium-competitive acid blocker (P-CAB). A 66-year-old man was admitted to our hospital complaining of disturbance of consciousness with evidence of hypomagnesemia noted on blood testing. The long-term use of vonoprazan was considered the cause of his hypomagnesemia, so it was discontinued, after which the hypomagnesemia improved. Hypomagnesemia can be induced not only by PPI treatment but also following the long-term use of P-CAB.

Obstructive cholangitis by mucus from an intraductal papillary mucinous neoplasm with pancreatobiliary fistula treated by endoscopic septotomy and direct peroral cholangioscopy: a case report.

Intraductal papillary mucinous neoplasms (IPMNs) occasionally form a fistula to adjacent organs, resulting in obstructive jaundice and cholangitis due to mucus obstruction. Although some procedures such as endoscopic nasobiliary drainage are attempted, they often do not work adequately because of high mucus viscosity. Herein, we report the case of an 87-year-old man with obstructive cholangitis treated by endoscopic septotomy and mucus suction with direct peroral cholangioscopy using conventional endoscopy. The patient incidentally showed a branched-type IPMN in the pancreatic head on computed tomography (CT) approximately 10-years ago. Although the patient's tumor had grown slowly and he occasionally developed cholangitis, he did not want surgery. He was admitted to our hospital because of cholangitis by mucus obstruction with a PB fistula. Endoscopic retrograde cholangiopancreatography (ERCP) and septotomy were performed. Septotomy made the duodenal papilla a large orifice, thereby facilitating spontaneous drainage of mucus. In addition, conventional endoscopy with a large working channel enabled direct access into the orifice and smooth mucus suction, thereby alleviating his cholangitis. In conclusion, septotomy and direct peroral cholangioscopy using conventional endoscopy could be useful to control biliary tract infection and obstructive jaundice due to mucus obstruction from an IPMNs with PB fistula.

Median arcuate ligament syndrome and aneurysm in the pancreaticoduodenal artery detected by retroperitoneal hemorrhage: A case report.

Here, we report a case with successful treatment of inferior pancreaticoduodenal artery aneurysm rupture due to celiac artery trunk compression caused by the median arcuate ligament. When clinicians see visceral aneurysms, the possibility of arcuate midline ligament compression syndrome (MALS) and ligamentectomy for MALS should be considered.

Case of pseudo-Meigs' syndrome caused by gastric cancer-related metastatic ovarian tumor with prolonged survival.

A 48-year-old woman presented with bilateral enlarged ovaries, ascites, bilateral pleural effusion, and advanced gastric cancer. Pleural fluid cytology did not reveal malignant cells. Oophorectomy, performed as a palliative procedure, was followed by rapid resolution of the pleural effusion and ascites. The patient was diagnosed with pseudo-Meigs' syndrome, and underwent chemotherapy followed by partial gastrectomy. At the last follow-up, 84 mo following oophorectomy, she was alive, and free of disease recurrence, despite not receiving any further treatment. Pseudo-Meigs' syndrome should be considered in patients with bilateral ovarian tumors, ascites and pleural effusion, and treatment such as oophorectomy may result in symptomatic improvement and better prognosis in similar patients.

Three cases of mediastinal pancreatic pseudocysts.

A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP), which is caused by tracking of pancreatic fluids through anatomical openings of the diaphragm into the mediastinum. Herein, we report the imaging characteristics of three cases of this condition. Our results revealed three features in common: (i) the connection between the mediastinum and the pancreatic cystic lesion; (ii) the presence of pleural effusions; and (iii) imaging findings consistent with chronic pancreatitis, such as pancreatic atrophy and calcifications and dilatation and/or stricture of main pancreatic duct (MPD). Serial diameter changes of the MPD and of the adjacent pseudocysts were necessary for the determination of the therapeutic strategy used in each case.

Xenon computed tomography can evaluate the improvement of hepatic hemodynamics before and after endoscopic injection sclerotherapy.

BACKGROUND: Xenon computed tomography (Xe-CT) provides quantitative information on tissue blood flow (TBF). In the present study, Xe-CT was performed in patients with esophagogastric varices (EGV) before and after endoscopic injection sclerotherapy (EIS) to evaluate hepatic blood flow (HBF), hepatic arterial TBF (HATBF) and portal venous TBF (PVTBF). METHODS: Subjects comprised of 88 patients with EGV (49 men, 39 women, average age 65.8 ± 11.5 years, median age 68 years, 30-86 years) and liver cirrhosis related to either hepatitis C virus (C) (n = 33), hepatitis B virus (B) (n = 3), alcohol (AL) (n = 22), AL + C (n = 7), AL + B (n = 1), B + C + AL (n = 1), nonalcoholic steatohepatitis (NASH) (n = 4), autoimmune hepatitis (AIH) (n = 5), primary biliary cirrhosis (PBC) (n = 2), or cryptogenic (n = 10) were enrolled. All patients, who were enrolled in this study, were performed EIS for prophylaxis. Xe-CT and measurement of the retention rate of indocyanine green 15 min after administration (ICG R15) were performed before and after EIS. Total hepatic TBF (THTBF) and PVTBF/HATBF ratio (P/A) were also calculated. RESULTS: PVTBF, HATBF, THTBF, P/A and ICG R15 before EIS were 28.3 ± 8.91, 22.5 ± 14.4 and 50.8 ± 17.6 ml/100 ml/min, 1.62 ± 0.71 and 28.8 ± 12.7 %, respectively and those after EIS were 31.9 ± 10.0, 19.3 ± 11.6, and 51.2 ± 17.0 ml/100 ml/min, 1.92 ± 0.84 and 23.6 ± 11.3 %, respectively. PVTBF and P/A after EIS were significantly higher than those before EIS (p = 0.00444, p = 0.0179, respectively), and HATBF and ICG R15 after EIS were significantly lower than those before EIS (p = 0.00129, p < 0.001, respectively). CONCLUSIONS: Xenon computed tomography showed that PVTBF increased after EIS for EGV and HATBF decreased in response to an increase in PVTBF.

Changes in levels of hepatitis B virus markers in patients positive for low-titer hepatitis B surface antigen.

AIM: Recently, patients positive for the low-titer hepatitis B surface antigen (HBsAg) have been found occasionally owing to the increase in the accuracy of detection methods. The aim of this study is to clarify the clinical status of acute hepatitis B virus (HBV) infection in patients positive for low-titer HBsAg. METHOD: Eight patients, who were positive for HBsAg at low titers and diagnosed as having acute HBV infection, were enrolled in this study. Assays of HBsAg, hepatitis B core antibody (anti-HBc), hepatitis B e-antigen (HBeAg), hepatitis B e-antibody (anti-HBe), hepatitis B surface antibody (anti-HBs) and HBV DNA, and biochemical tests were basically conducted every 4 weeks for at least 24 weeks. RESULT: The average cut-off index of HBsAg was 8.7 ± 9.6 (range, 1.0-25.7). All the patients were negative for anti-HBc, HBeAg, anti-HBe and HBV DNA on their initial visit. The genotype of HBV could be determined in four patients: two were infected with genotype B/HBV, one was infected with genotype A/HBV, and the remaining patient was infected with genotype C/HBV. Although HBsAg clearance was observed within 4 months in all the patients, none of the other HBV markers seroconverted during the observation period. CONCLUSION: HBV infection terminating with seronegativity for HBV markers may occur in transient HBV infection.

Effect of nucleoside analog-interferon sequential therapy on patients with acute exacerbation of chronic hepatitis B.

AIM: Nucleoside analog (NA)-interferon (IFN) sequential therapy may enable the long-term control of chronic hepatitis B (CHB) and the withdrawal of the nucleoside analog. We evaluated the efficacy of NA-IFN sequential therapy for acute exacerbation of CHB. METHODS: A total of 12 patients with acute exacerbation of CHB, nine of whom were positive for hepatitis B e antigen (HBeAg), were enrolled in this study. All the patients were treated with lamivudine 100 mg/day alone for 20 weeks, then with both IFN-alpha 6 megaunits three times per week and lamivudine for 4 weeks, and lastly, with IFN-alpha alone for 20 weeks. Patients whose serum alanine aminotransferase (ALT) level was normalized, whose serum hepatitis B virus (HBV) DNA level decreased to less than 5 log copies/mL, and HBeAg level was absent 24 weeks after the end of treatment were defined as having sustained virological response (SVR). The other patients were defined as having no response (NR). RESULTS: Four out of nine (44.4%) HBeAg-positive and all three HBeAg-negative patients achieved SVR. The levels of serum alanine aminotransferase (ALT), HBV DNA and HBV core-related antigen were similar between SVR and NR patients at baseline. Three of four patients (75.0%) whose serum HBeAg became negative at the end of treatment achieved SVR, while one of five (20.0%) whose serum HBeAg remained positive achieved SVR. CONCLUSION: NA-IFN sequential therapy for patients with acute exacerbation of CHB enables the withdrawal of treatment and is particularly effective for patients whose serum HBeAg has become undetectable by the end of the IFN treatment.

Short-term prolongation of pegylated interferon and ribavirin therapy for genotype 1b chronic hepatitis C patients with early viral response.

AIM: We tailored extended treatments using pegylated interferon (PEG IFN) and ribavirin (RBV) to viral responses after initiation of therapy and investigated the efficacy and safety of its therapy for chronic hepatitis C (CHC) patients. METHODS: Eighty-two genotype 1b CHC patients were enrolled in the present study. All patients received PEG IFN-alpha-2b and weight-based RBV therapy. We defined a viral response in which serum HCV-RNA is undetectable at week 4 as rapid viral response (RVR), detectable at week 4 and undetectable by week 12 as early viral response (EVR), and detectable at week 12 and undetectable by week 24 as late viral response (LVR). We set the treatment duration depending on viral response; 48 weeks for RVR patients and 72 weeks for LVR. Furthermore, EVR patients received a short-term extension of treatment duration to 52-60 weeks. We prospectively investigated sustained viral response (SVR) rates of these groups. RESULTS: Overall SVR rate for the total patient group was 57.3%. SVR rates of the RVR, EVR and LVR patients were 100%, 80.5% and 40.0%, respectively. Nine patients could not complete this treatment protocol. Baseline platelet count and mutation in the interferon sensitivity-determining region of NS5A were significant independent predictors of SVR, and amino acid substitution of the core region was a significant independent predictor of non-viral response by multivariate logistic regression analyses. CONCLUSION: The results indicate that short-treatment extension of PEG IFN plus RBV treatment protocols in EVR patients can improve overall SVR rates.

[Two cases of anaplastic carcinoma of the pancreas in terms of the diversity of carcinoma cells (epithelial-mesenchymal transition; EMT)].

The first evaluated case was a 71-year-old man with melaena. A huge tumor mass was observed in the tale of the pancreas, which we diagnosed as pancreatic carcinoma. Pathological findings confirmed that it was anaplastic pancreas carcinoma (giant cell type). The second case was a 61-year-old woman with upper abdominal pain. Irregular tumors with scattered cysts were observed in the tale of the pancreas, which rapidly increased. Autopsy findings confirmed that it was anaplastic pancreas carcinoma (pleomorphic type). Both cases showed positive for epithelial marker and mesenchymal markers and decrease in stainability by E-cadherin staining, a result which suggested diversity of tumor cells in anaplastic pancreas carcinomas.

Insufficient radiofrequency ablation therapy may induce further malignant transformation of hepatocellular carcinoma.

BACKGROUND: Radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is a thermoablative technique to kill tumor tissue by generating areas of coagulative necrosis. Recent reports have raised concern that RFA may lead to a local recurrence of HCC with an aggressive phenotype and unfavorable prognosis, suggesting that RFA may induce further malignant transformation of HCC. However, the biological effects of RFA on HCC cells have not been directly analyzed. The aim of this study was to determine whether heat stress of the type associated with RFA induces malignant transformation of HCC. METHODS: We assessed the sensitivity of three HCC cell lines (HepG2, Alexander, and Huh7) to heat treatment for 10 min. We then determined the temperature at which a heat-resistant subline can be generated. We established and expanded sublines that survived heat treatment. And their proliferation rates, heat sensitivities, and invasive capacities were further examined. RESULTS: All HepG2 died after 48 degrees C treatment, whereas 49 degrees C treatment was required to kill all Alexander and HuH7. We generated 20 sublines for each parental cell line. A HepG2 subline, HepG2#18, proliferated 100% faster than parental HepG2. Moreover, HepG2#18 survived after 50 degrees C treatment, whereas all parental HepG2 died after heat treatments at 48 degrees C or higher. CONCLUSION: Our results showed that even a single heat treatment could induce further transformation of an HCC cell line. Our results suggest that an insufficient treatment of HCC by RFA that enables survival of some cells might induce further malignant transformation in vivo.

Safer endoscopic gastric mucosal resection: preoperative proton pump inhibitor administration.

BACKGROUND AND AIM: Control of bleeding is crucial in improving the safety of endoscopic mucosal resection (EMR), and intragastric acidity has a great impact on hemostasis and blood coagulation. Proton pump inhibitors (PPI) are potent suppressors of gastric acid; however, PPI need to be continuously administered orally for several days, and thus initial effects may be insufficient if PPI is only administered immediately after EMR. The aim of this study was to determine whether preoperative administration of PPI prior to EMR can elevate intragastric acidity, facilitate better control of intraoperative bleeding (complete coagulation and hemostasis), prevent postoperative bleeding, and facilitate healing of artificial ulcers. METHODS: A randomized clinical study was conducted in which EMR was performed with or without 1 week of preoperative PPI administration. RESULTS: Artificial ulcers created by EMR healed more rapidly in patients who received preoperative PPI. CONCLUSIONS: The results of the study suggest that preoperative administration of PPI before EMR is useful for controlling and preventing bleeding, and for facilitating the healing of artificial ulcers.

[Pilot study of concomitant TS-1/CDGP radiotherapy for esophageal cancer].

Although surgery is treatment of choice for esophageal cancer, radiochemotherapy is being employed throughout Japan for the purpose of improving patient QOL. The results of this therapy are reported to be comparable to those associated with surgical treatment. However, since concomitant 5-FU/CDDP radiotherapy, currently the treatment of choice when implementing radiochemotherapy, is associated with a comparatively high incidence of gastrointestinal disorders and requires continuous intravenous infusion for 24 hours, it lowers the level of patient QOL. We have proposed a clinical study of concomitant TS-1/CDGP radiotherapy for the purpose of maintaining patient QOL and improving outcome. We conducted a pilot study prior to the phase I and II studies. The study was conducted on six cases and favorable results were obtained, consisting of a CR rate of 66.7% and a two-year survival rate of 50%. Although bone marrow inhibition was observed as an adverse side effect, gastrointestinal disorders that were discernible to the patients were extremely mild, and patient QOL was able to be maintained. CR was observed in 2 cases who were positive for DPD as determined by immunostaining. We are planning on conducting phase I and II studies in the future based on the potential for this treatment to contribute to the preservation of patient QOL and improve prognosis.