HBV Reactivation After Bariatric Surgery for HBV-Infected Obese Patients.

BACKGROUND: The association between non-alcoholic fatty liver disease and hepatitis B virus (HBV) infection is inconclusive. The aim of this study was to investigate the viral dynamic of HBV and its association with change of body mass index (BMI), aspartate transaminase (AST), and alanine transaminase (ALT) levels after bariatric surgery. METHODS: Patients who underwent bariatric surgery between June 2011 and May 2014 were selected in this retrospective study. BMI, AST, ALT, and HBV DNA levels were calculated pre-operatively and at 1st, 3rd, and 6th postoperative months. RESULTS: Two hundred and seventy-nine patients including 34 (12.2%) HBsAg-positive and 245 (87.8%) HBsAg-negative patients were enrolled. Eighteen HBsAg-positive and HBeAg-negative patients were matched with 36 HBsAg-negative patients. A significant decrease in BMI was found since 1st postoperative month in both groups. AST and ALT increased at 1st postoperative month, but decreased at 3rd and 6th postoperative months in both groups. However, a significant increase in HBV DNA level was observed in HBeAg-negative patients since 1st postoperative month with the highest peak at 3rd postoperative month. HBV reactivation occurred in 4 out of 17 (23.5%) patients, 8 out of 16 (50.0%) patients, and 4 out of 12 (33.3%) patients at 1st, 3rd, and 6th postoperative months, respectively. The change of HBV DNA was not associated with change of BMI, AST, or ALT after bariatric surgery. CONCLUSION: Bariatric surgery can achieve significant weight loss and improvement of liver function tests. However, there existed significant risk of HBV reactivation after bariatric surgery for patients with obesity.

Derivation and validation of a scoring system for predicting nonalcoholic steatohepatitis in Taiwanese patients with severe obesity.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is common in severely obese Asians and may progress to advanced liver disease. Although invasive, liver biopsy is the gold standard for NASH diagnosis. Scoring systems for predicting NASH in obese Asians are scarce. OBJECTIVES: To develop and validate a scoring system to predict NASH in Taiwanese patients with severe obesity. SETTING: University hospital, Taiwan. METHODS: Preoperative clinical and laboratory data were obtained from 180 severely obese patients who underwent bariatric surgery. NASH was evaluated by liver histopathology. Patients were divided into 2 groups: a derivation cohort (n = 120) and a validation cohort (n = 60). RESULTS: Of the 180 patients, 91 (50.6%) had NASH. Multivariate analysis identified body mass index (BMI), alanine aminotransferase (ALT), and triglyceride as independent predictors for NASH in the derivation group. A weighted sum of the score was: [(1 for presence of 45 kg/m2 ≧ BMI>40 kg/m2) or (2 for presence of BMI>45 kg/m2)+(2 for presence of ALT>40 IU/L)+(1 for presence of triglyceride>140 mg/L)]. The area under the receiver operating characteristic curve of this model was .80 and .82 in derivation and validation cohort, respectively. Patients were further divided into low- and high-risk for NASH by using a cutoff score of 3. Diagnostic accuracy was 74% and 80% in derivation and validation cohorts, respectively. CONCLUSION: We developed and subsequently validated a simple clinical scoring system incorporating BMI, ALT, and triglyceride to predict NASH in Taiwanese patients with severe obesity.

Interactions of a PPARGC1A Variant and a PNPLA3 Variant Affect Nonalcoholic Steatohepatitis in Severely Obese Taiwanese Patients.

The patatin-like phospholipase domain-containing protein 3 (PNPLA3) variant is associated with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). However, the role of genetic variations of the peroxisome proliferator-activated receptor gamma coactivator-1-alpha gene (PPARGC1A) and glucokinase regulatory (GCKR) gene on NASH in obese patients remains unclear. We studied the effects and interaction of these genetic polymorphisms on NASH in severely obese Taiwanese patients.The genotypes of PPARGC1A rs8192678, PNPLA3 rs738409, and GCKR rs780094 were determined in 177 severely obese patients who underwent bariatric surgery. NASH was evaluated by liver histopathology.Of 177 patients, 29 (16.4%), 57 (33.2%), and 91 (51.4%) were in the non-NAFLD, steatosis, and NASH groups, respectively. We found that the PPARGC1A and PNPLA3 variants, but not the GCKR variant, were associated with NASH. The PPARGC1A rs8192678 GA/AA genotype was associated with higher steatosis grade and presence of ballooning degeneration. The PNPLA3 rs738409 GG genotype was associated with higher severity in all histologic features except for fibrosis. In multivariate analysis, both the PPARGC1A rs8192678 GA/AA genotype (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.08-4.98; P = 0.031) and the PNPLA3 rs738409 GG genotype (OR 4.05; 95% CI 1.24-13.23; P = 0.021), and also body mass index were independent risk factors for NASH. Further, there was an additive effect of the PPARGC1A rs8192678 GA/AA genotype and the PNPLA3 rs738409 GG genotype on the presence of NASH (OR 6.83; 95% CI 1.61-29.01; P = 0.009).The PPARGC1A rs8192678 GA/AA genotype and the PNPLA3 rs738409 GG genotype had an additive effect on NASH in severely obese Taiwanese patients.

The Overexpression of FEN1 and RAD54B May Act as Independent Prognostic Factors of Lung Adenocarcinoma.

Synthetic lethality arises when a combination of mutations in two or more genes leads to cell death. However, the prognostic role of concordant overexpression of synthetic lethality genes in protein level rather than a combination of mutations is not clear. In this study, we explore the prognostic role of combined overexpression of paired genes in lung adenocarcinoma. We used immunohistochemical staining to investigate 24 paired genes in 93 lung adenocarcinoma patients and Kaplan-Meier analysis and Cox proportional hazards models to evaluate their prognostic roles. Among 24 paired genes, only FEN1 (Flap endonuclease 1) and RAD54B (RAD54 homolog B) were overexpressed in lung adenocarcinoma patients with poor prognosis. Patients with expression of both FEN1 and RAD54B were prone to have advanced nodal involvement and significantly poor prognosis (HR = 2.35, P = 0.0230). These results suggest that intensive follow up and targeted therapy might improve clinical outcome for patients who show expression of both FEN1 and RAD54B.

PNPLA3 genotype increases susceptibility of nonalcoholic steatohepatitis among obese patients with nonalcoholic fatty liver disease.

BACKGROUND: The patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs738409 variant is associated with histologic disease severity in patients with nonalcoholic fatty liver disease (NAFLD); however, whether the PNPLA3 genotype has an effect on susceptibility of nonalcoholic steatohepatitis (NASH) from NAFLD among severely obese patients remains unclear. The objective of this study was to investigate the role of the PNPLA3 genotype on NASH in severely obese Asian patients with NAFLD. METHODS: The PNPLA3 rs738409 genotype was determined in 181 severely obese patients who underwent bariatric surgery. The diagnosis of NASH and the NAFLD activity score (NAS) were determined by liver histopathology. RESULTS: Of the 181 patients, 29 (16.0%), 60 (33.2%), and 92 (50.8%) were in the non-NAFLD, steatosis, and NASH groups, respectively. The PNPLA3 rs738409 GG genotype was associated with higher liver enzymes and a higher risk for NASH (odds ratio [OR], 3.72; 95% CI, 1.25-11.05). The GG genotype was also associated with histologic severity of NAFLD, including higher steatosis grade (OR, 9.94; 95% CI, 2.20-44.83 for patients with grade 3 steatosis) and NAS (OR, 11.49; 95% CI, 2.50-52.83 for patients with a NAS ≥5). Finally, multiple logistic regression also showed that the GG genotype was an independent risk factor for NASH (OR, 3.58; 95% CI, 1.15-11.12) in NAFLD patients. CONCLUSION: The PNPLA3 rs738409 GG genotype increases susceptibility of NASH in severely obese Asians with NAFLD and correlates to histologic severity of NAFLD.

Endoscopic submucosal dissection for early esophageal neoplasia: a single center experience in South Taiwan.

BACKGROUND/PURPOSE: Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure to resect early gastrointestinal neoplasm. It is technically more difficult and risky when used to treat early esophageal tumors. We report our experiences related to performing ESD for early esophageal neoplasia. The efficacy, complications, and outcome were also analyzed. METHODS: From December 2007 to April 2010, 22 patients with documented early esophageal neoplasm underwent ESD. All patients completed a meticulous endoscopic examination using conventional endoscopy followed by narrow-band imaging. Lugol's staining was performed to identify the margin of the suspicious lesion. Insulation-tipped diathermic knife 2 was used for ESD. RESULTS: A total of 26 neoplastic lesions (including 13 tumors with high-grade dysplasia, 12 tumors with squamous cell carcinoma, and one tumor with adenocarcinoma) in 22 patients were enrolled. All patients were men. The mean age was 47.6 ± 8.6 years (range, 30-68 years). The mean size of tumors was 33.7 ± 21.7 mm (range, 8-80 mm). ESD was performed for 24 lesions in 20 patients. The mean size of resected specimens was 43.1 ± 19.2 mm (range, 15-90 mm). The mean operation time was 92.7 ± 69 minutes (range, 30-310 minutes). There were three ESD-related complications, including one with delayed bleeding, one with subcutaneous emphysema, and one with perforation. Two patients received additional operations after ESD due to deep submucosal invasion by cancer. Three lesions in two patients (12.5%) developed post-ESD esophageal stricture that needed repeated endoscopic bougination. There was no procedure-related mortality. No local recurrence was found during the follow-up period. CONCLUSION: ESD is a promising local curative treatment option for early esophageal neoplasia in Taiwan. However, this procedure may result in complications that are worth noting, especially post-ESD esophageal stricture. Education regarding this procedure and more hands-on training will facilitate endoscopists to improve the outcomes of patients undergoing this procedure.

Improvement of nonalcoholic fatty liver disease after bariatric surgery in morbidly obese Chinese patients.

BACKGROUND: Obesity is a risk factor for nonalcoholic fatty liver disease (NAFLD), which appears to improve after weight loss induced by bariatric surgery in Western countries. The present study aims to determine the alterations of clinical measurements and liver histology of NAFLD after bariatric surgery in morbidly obese Chinese patients. METHODS: Between November 2006 and December 2007, 21 morbidly obese patients receiving intra-operative liver biopsy and follow-up liver biopsy 1 year after laparoscopic Roux-en-Y gastric bypass were enrolled. NAFLD activity score (NAS) and fibrosis stage were histologically evaluated. RESULTS: The mean body mass index fell from 43.8 ± 7.5 to 28.3 ± 4.6 kg/m(2) (P < 0.01). Biochemical improvement was found in serum levels of alanine aminotransferase (P < 0.01) and γ-glutamyltransferase (P < 0.01), but not aspartate aminotransferase (P = 0.66). Histological improvement was noted in NAS (P < 0.01) and individual components, including steatosis (P < 0.01), ballooning degeneration (P < 0.01), and lobular inflammation (P = 0.02). Pre-operatively, 4 (19.0%), 11 (52.4%), and 6 (28.6%) patients were found to have NAS >/=5, 3 or 4, and

Prospective survey for the etiology and outcome of peptic ulcer bleeding: a community based study in southern Taiwan.

BACKGROUND/PURPOSE: Helicobacter pylori infection and drugs are the two major risk factors for peptic ulcer bleeding. The role of these two factors may change with changes in the prevalence of H pylori and use of NSAIDs. This study aimed to determine the cause, endoscopic features, and outcome of peptic ulcer bleeding in a community hospital in southern Taiwan. METHODS: Patients who received esophagogastroduodenoscopy on arrival at the emergency department and were found to have actively bleeding ulcers or ulcers with stigmata of recent hemorrhage were included. H pylori infection was documented by the rapid urease test, histology, and/or C-13 urease breath test. Medication history, comorbidities, requirement for endoscopic therapy, blood transfusion, hospitalization days, and rebleeding rates were analyzed. RESULTS: A total of 204 patients were enrolled with a mean age of 64.8 ± 15.2 years, with 58.3% of the subjects being female. There were 62 patients (30.4%) with H pylori infection only, 40 patients (19.6%) with drug use only, 67 patients (32.8%) with H pylori infection and drug use, and 37 patients (17.2%) without H pylori or drug use. A total of 107 patients (52.5%) were found to have had drug exposure. Drug exposure had an odds ratio (OR) of 2.34 [95% Confidence Interval (CI) = 1.30-4.20] for gastric ulcer bleeding and H pylori had an OR of 2.64 (95% CI = 1.17-5.97) for combined gastric and duodenal ulcer bleeding. The mean hospitalization period was 5.7 ± 4.0 days and the overall re-bleeding rate was 4.0%. The H pylori negative and drug negative subjects needed more endoscopic therapy (p < 0.05). CONCLUSION: Drug use, especially NSAIDs, aspirin, and clopidogrel has become an important cause of peptic ulcer bleeding in southern Taiwan.

Risk factors for developing synchronous esophageal neoplasia in patients with head and neck cancer.

BACKGROUND: This study investigated the risk factors for synchronous esophageal neoplasia in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: All 315 consecutive patients with newly diagnosed HNSCC received endoscopic esophageal screening with image-enhanced endoscopy. RESULTS: Sixty-nine patients (21.9%) had synchronous esophageal neoplasia, 37 (53.6%) with superficial neoplasia and 21 (30.4%) with multiple esophageal lesions. Univariate analysis revealed age <50 years, drinking alcohol, and location of index HNSCC were significant risk factors for developing synchronous esophageal neoplasia. In multivariate analysis, drinking alcohol (odds ratio [OR], 3.792; p = .0035), index oropharynxgeal cancers (OR, 3.618; p = .0045) and hypopharyngeal cancers (OR, 2.627; p = .0029) were independent risk factors. Drinking alcohol was clearly dose-response related (p = .001). CONCLUSION: Alcohol consumption and index tumor location are associated with the development of synchronous esophageal neoplasia in patients with HNSCC. Because of the high prevalence, routine endoscopic examination of the esophagus should be recommended, especially in patients with the risk factors identified.

Multiple bowel intussusceptions from metastatic localized malignant pleural mesothelioma: a case report.

Localized malignant pleural mesothelioma (LMPM) is a rare occurrence, and gastrointestinal intra-luminal metastases have not previously been reported. Herein, we report a patient with LMPM who presented with a local recurrence 10 mo after initial en bloc surgical resection. Abdominal computed tomography was performed for intractable, vague abdominal pain with episodic vomiting, which showed a "target sign" over the left lower quadrant. Laparotomy revealed several intra-luminal metastatic tumors in the small intestine and colon and a segmental resection of metastatic lesions was performed. Unfortunately, the patient died of sepsis despite successful surgical intervention. Though local recurrence is more frequent in LMPM, the possibility of distant metastasis should not be ignored in patients with non-specific abdominal pain.

Suture knot embolism--a rare complication of percutaneous arterial closure device.

Percutaneous closure devices used after percutaneous endovascular procedures have become more popular over the past decade. Occlusive vascular complication of the device is rare but always leads to limb-threatening consequence. We report a case of arterial occlusion caused by distal embolization of the suture material in the percutaneous closure device.

The application of Prague C and M criteria in the diagnosis of Barrett's esophagus in an ethnic Chinese population.

OBJECTIVES: To investigate the prevalence of endoscopically suspected esophageal metaplasia (ESEM) in an ethnic Chinese population by endoscopic and pathologic evaluation and to assess the utility of Prague C and M criteria. METHODS: Consecutive patients who received esophagogastroduodenoscopy either as a part of therapy for various upper abdominal symptoms or as an annual health check-up were evaluated for the existence of ESEM and Barrett's esophagus (BE). Biopsy with standardized random four pieces every 2 cm from the four quarters of esophagus with ESEM lesion was performed. BE was defined by histological verification of specialized intestinal metaplasia and gastric metaplasia and was categorized according to the Prague C and M criteria. RESULTS: A total of 5,179 subjects were screened from Jan. 2007 to Dec. 2007. This study enrolled 4,797, including 3,386 for referral endoscopy and 1,411 for screening endoscopy. Prevalence of BE among the referral endoscopy, screening endoscopy, and overall was 1.06%, 0.35%, and 0.85%, respectively. A total of 41 subjects with BE were detected among 93 ESEM subjects. Short segment BE (75.6%, n=31) was more prevalent than long segment BE (24.4%, n=10). The proportions of BE from subjects with ESEM by Prague C and M criteria were C< or =1M1 38.9% (19/50), C< or =1M2 40% (12/30), and CxM> or =3 76.9% (10/13). CONCLUSIONS: On the basis of the standardized protocol with random four-quadrate endoscopic biopsy, we have demonstrated the utility of Prague C and M criteria to characterize the BE in an ethnic Chinese population.

Fibrosing mediastinitis as a rare sequel of iatrogenic rupture of bronchogenic cyst--a case report.

Fibrosing mediastinitis is a chronic disease process with a spectrum of etiology. We report a 51-year-old female who underwent incision and drainage procedure in the neck for deep neck and mediastinal abscess. Five years later she developed fibrosing mediastinitis. This lesion infiltrated from neck base into the upper mediastinum with tracheal compression and vessel encasement. She had resection of the lesion which proved to be a ruptured bronchogenic cyst with chronic inflammation. This rare case illustrates the importance of including inflammatory bronchogenic cyst in the etiology of deep neck abscess formation. And we further find a ruptured bronchogenic cyst with chronic inflammation as an etiology of fibrosing mediastinitis.

Clonorchiasis-associated perforated eosinophilic cholecystitis.

Clonorchiasis, a disease caused by infection with Clonorchis sinensis, is endemic in the Far East. Cholelithiasis, pyogenic cholangitis, cholecystitis, and biliary tract obstruction are common complications of chronic infection. Although cholecystitis caused by clonorchiasis is common, it is rarely reported as resulting from eosinophilic infiltration. We report a rare case of clonorchiasis-associated perforated eosinophilic cholecystitis and review the relevant literature.

Tension pneumocephalus--a rare complication of radiotherapy: a case report.

We present a rare case of tension pneumocephalus due to high-dose radiotherapy used to treat nasopharyngeal carcinoma. A skull base defect causing tension pneumocephalus was identified and was repaired successfully. The case emphasizes the importance of careful consideration before applying irradiation treatment to patients with head and neck malignancy and urges early detection of potentially life-threatening complications.