[Guidelines for prevention and treatment of colorectal adenoma with integrated Chinese and western medicine].

The Guidelines for prevention and treatment of colorectal adenoma with integrated Chinese and western medicine are put forward by Nanjing University of Chinese Medicine and approved by China Association of Chinese Medicine. According to the formulation processes and methods of relevant clinical practice guidelines, the experts in clinical medicine and methodology were organized to discuss the key problems to be addressed in the clinical prevention and treatment of colorectal adenoma(CRA) and provided answers following the evidence-based medicine method, so as to provide guidance for clinical decision-making. CRA is the major precancerous disease of colorectal cancer. Although the prevention and treatment with integrated Chinese and western medicine have been applied to the clinical practice of CRA, there is still a lack of high-quality guidelines. Four basic questions, 15 clinical questions, and 10 outcome indicators were determined by literature research and Delphi questionnaire. The relevant randomized controlled trial(RCT) was retrieved from CNKI, Wanfang, VIP, SinoMed, PubMed, EMbase, Cochrane Library, Web of Science, and 2 clinical trial registries, and finally several RCTs meeting the inclusion criteria were included. The data extracted from the RCT was imported into RevMan 5.3 for evidence synthesis, and the evidence was evaluated based on the Grading of Recommendations, Assessment, Development, and Evaluations(GRADE). The final recommendations were formed by the nominal group method based on the evidence summary table. The guidelines involve the diagnosis, screening, treatment with integrated Chinese and western medicine, prevention, and follow-up of colorectal adenoma, providing options for the clinical prevention and treatment of CRA.

Clinical outcomes of endoscopic submucosal dissection for laterally spreading tumors involving the dentate line.

OBJECTIVE: Endoscopic submucosal dissection (ESD) for laterally spreading tumors (LST) involving the dentate line (LST-DL) is challenging because of the specific anatomical features of the anorectum. This study aimed to evaluate the efficacy and safety of ESD for LST-DL. METHODS: Consecutive patients with LST-DL who had undergone ESD at our hospital between January 2010 and December 2015 were retrospectively enrolled in this study. Rates of en bloc resection, R0 resection, and complications, pathological characteristics, and tumor recurrence were analyzed and compared with those of LST in the rectum not involving the dentate line (LST-NDL). RESULTS: Altogether 49 patients with LST-DL (median age 63 years; 39 women; median lesion size 57 mm; median follow-up period of 24 months) and 96 patients with LST-NDL (median age 67 years; 31 women; median lesion size 47 mm; median follow-up period of 31 months) were enrolled. En bloc resection (93.9% [46/49] vs 94.8% [91/96]) and en bloc R0 resection rates (83.7% [41/49] vs 88.5% [85/96]), respectively, for LST-DL and LST-NDL, with no significant differences. However, ESD for LST-DL had a longer procedure time (77 min vs 54 min, P = 0.02), a greater postprocedural perianal pain rate (28.6% vs 0%, P < 0.001), and more anal strictures (4.1% vs 0%, P = 0.04). The complication rates of perforation, bleeding and fever, recurrence rate, and pathological characteristics did not differ between the two groups. CONCLUSIONS: ESD is a safe and effective therapeutic modality for LST-DL. However, this procedure should be performed by experienced endoscopists and the difficulty needs to be fully considered.

Risk factor analysis of post-ERCP cholangitis: A single-center experience.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) may have complications. Our study aimed to investigate the risk factors and prevention of post-ERCP cholangitis. METHODS: We retrospectively analyzed 4234 cases undergone ERCP in the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2008 to December 2013. Patient-related factors and procedure-related factors were analyzed to find the risk factors of post-ERCP cholangitis. The time point of post-ERCP cholangitis was also analyzed. Univariate and multivariate analyses were performed to define the independent risk factors of post-ERCP cholangitis. RESULTS: The success rate of ERCP was 96.8% (4099/4234). The overall complication rate was 9.4% (399/4234). Post-ERCP cholangitis occurred in 102 cases (2.4%, 102/4234). The most dangerous time of post-ERCP cholangitis was from 24 h-48 h after ERCP (45.1%, 46/102). Univariate analysis revealed that age, hypertension, diabetes, previous ERCP history, biliary stent insertion, pancreatography, endoscopic sphincterotomy, balloon dilation and hilar obstruction were risk factors of post-ERCP cholangitis (P < 0.05). Multivariate analysis indicated that age, previous ERCP history and hilar obstruction were independent risk factors (P < 0.05). While endoscopic stone extraction was the potential protective factor. CONCLUSIONS: Many risk factors are involved in post-ERCP cholangitis. Among them, old age, previous ERCP history and hilar obstruction were independently related to this post-ERCP complication.

Over-the-scope clip to close a gastrocutaneous fistula after esophagectomy.

Over-the-scope clip (OTSC) system is becoming a new reliable technique which is available for the endoscopic closure of fistulas, bleeding, perforations and so on. We describe the case of a patient with a non-healing gastrocutaneous fistula after esophagectomy for esophageal squamous cell carcinoma which was successfully closed using an OTSC system. This is the first report of the use of OTSC to treat a non-healing gastrocutaneous fistula successfully after esophagectomy. We believe our experience will give such patients an ideal way to cure the fistula without suffering too much and also explore new application of OTSC.

Effectiveness of peroral endoscopic myotomy in the treatment of achalasia: a pilot trial in Chinese Han population with a minimum of one-year follow-up.

OBJECTIVE: To investigate the outcomes of Chinese Han patients who underwent peroral endoscopic myotomy (POEM) for achalasia. METHODS: Patients undergoing POEM for achalasia at the Affiliated Drum Tower Hospital of Nanjing University Medical School were prospectively enrolled in this study, with a follow-up duration of at least one year. Their outcomes were evaluated by analyzing esophageal manometry, timed barium esophagogram and 36-Item Short Form Health Survey (SF-36), which were performed before surgery, 5 days after surgery and at the last follow-up. Patients' symptom relief was considered the primary outcome. Secondary outcomes included lower esophageal sphincter (LES) pressure, esophageal emptying, patients' quality of life (QoL) and procedure-related complications. RESULTS: Eighty-seven patients were included in the study. Eckardt score after POEM was remarkably lower than the preoperative score (0.4 ± 0.7 vs 7.1 ± 2.1, P = 0.001). The preoperative LES pressure was 32.4 ± 15.3 mmHg, which was decreased to 3.8 ± 3.9 mmHg immediately after surgery. The height of the barium column at 1 min after barium swallow was significantly reduced after treatment (11.7 ± 1.2 cm vs 3.2 ± 1.6 cm, P < 0.001). The patients' QoL was also improved, as indicated by obviously increased physical and mental component summary (PCS and MCS) scores of the SF-36. Complications occurred during POEM included cutaneous emphysema, mucosal injury and pneumothorax. CONCLUSION: POEM is an effective approach for treating achalasia, which can relieve the symptoms of achalasia by improving esophageal emptying and lowering LES pressure.

[Effect of Akt on the function of esophageal squamous cancer cell Eca109 and the expression of vasculogenic mimicry-related genes].

OBJECTIVE: To investigate the inhibitory effect of siRNA targeting Akt on the biological behavior of esophagus squamous cell carcinoma cell line in vitro and to explore the relationship between Akt and vasculogenic mimicry (VM)-related genes in esophageal squamous cell carcinoma. METHODS: The plasmid-harboring small interfering RNA targeting Akt was introduced into Eca109 cells by liposome-mediated transfection. The proliferation of Eca109 cell was determined by colony formation assay. The cellular migration was evaluated by Transwell migration assay. And three dimensional cell culture was employed to observe and count the number of capillary structure for each cell group. Flow cytometry (FCM) was used to detect the apoptotic rate of Eca109, Eca109/Neo and Eca109/siRNA Akt cells under normoxia exposure. The apoptotic rate was assessed by Annexin V/7-AAD double labeling. And the expressions of Akt and matrix metalloproteinase-2 (MMP-2) protein were detected by Western blotting. RESULTS: The results of Western blotting showed that the expression of Akt in stably transfected group were significantly lower than empty carrier and untransfected groups (0.03 ± 0.01 vs 1.49 ± 0.39 and 1.47 ± 0.41, both P < 0.05). Transwell migration assay showed that fewer Eca109/8 cells could move through the artificial basement membrane as compared with untransfected and empty carrier groups (48 ± 9 vs 128 ± 10 and 122 ± 11, both P < 0.05). Clone formation number of stably transfected group was significantly lower than empty carrier and untransfected groups (63 ± 7 vs 148 ± 11 and 163 ± 15, both P < 0.05). Annexin V/7-AAD double standard method demonstrated that the apoptotic rate of stably transfected group was much more than those of untransfected and empty carrier groups (12.2% ± 1.6% vs 4.8% ± 0.8% and 4.2% ± 0.8%, both P < 0.05). Eca109 and Eca109/Neo cells were capable of forming the in vitro structures of VM. And the number of tube-shaped structure in stably transfected group was markedly less than those of untransfected and empty carrier groups (14.0 ± 1.2 vs 30.0 ± 1.2 and 27.7 ± 1.5, both P < 0.05). MMP-2 protein expression in stably transfected group was less than those of untransfected and empty carrier groups (both P < 0.05). CONCLUSIONS: The PI(3)K/Akt pathway is involved in the regulation of VM formation in esophageal squamous cell carcinoma through the action of MMP-2. Blockade of this pathway may provide a new therapeutic approach to human esophagus squamous cell carcinoma.

Neoadjuvant chemoradiotherapy for resectable esophageal carcinoma: a meta-analysis.

AIM: To compare neoadjuvant chemoradiotherapy and surgery with surgery alone for resectable esophageal carcinoma. METHODS: We used MEDLINE and EMBASE databases to identify eligible studies and manual searches were done to ensure no studies were missed. Trial validity assessment was performed and a trial quality score was assigned. RESULTS: Eleven randomized controlled trials (RCTs) including 1308 patients were selected. Neoadjuvant chemoradiotherapy significantly improved the overall survival compared with surgery alone. Odds ratio (OR) [95% confidence interval (CI), P value], expressed as neoadjuvant chemoradiotherapy and surgery vs surgery alone, was 1.28 (1.01-1.64, P = 0.05) for 1-year survival, 1.78 (1.20-2.66, P = 0.004) for 3-year survival, and 1.46 (1.07-1.99, P = 0.02) for 5-year survival. Postoperative mortality increased in patients treated by neoadjuvant chemoradiotherapy (OR: 1.68, 95% CI: 1.03-2.73, P = 0.04), but incidence of postoperative complications was similar in two groups (OR: 1.14, 95% CI: 0.88-1.49, P = 0.32). Neoadjuvant chemoradiotherapy lowered the local-regional cancer recurrence (OR: 0.64, 95% CI: 0.41-0.99, P = 0.04), but incidence of distant cancer recurrence was similar (OR: 0.94, 95% CI: 0.68-1.31, P = 0.73). Histological subgroup analysis indicated that esophageal squamous cell carcinoma did not benefit from neoadjuvant chemoradiotherapy, OR (95% CI, P value) was 1.16 (0.85-1.57, P = 0.34) for 1-year survival, 1.34 (0.98-1.82, P = 0.07) for 3-year survival and 1.41 (0.98-2.02, P = 0.06) for 5-year survival. CONCLUSION: Neoadjuvant chemoradiotherapy can raise the survival rate of patients with esophageal adenocarcinoma.

Common single nucleotide polymorphism of hypoxia-inducible factor-1alpha and its impact on the clinicopathological features of esophageal squamous cell carcinoma.

OBJECTIVE: Angiogenesis is one of the most important molecular events in solid tumor development and growth, in which hypoxia-inducible factor (HIF)-1alpha is a key regulator and plays an important role. Studies have shown that a single nucleotide polymorphism (C1772T) in the HIF-1alpha gene exerts a large effect on the phenotype of human head and neck squamous cell carcinoma and renal cell carcinoma. But the impact of the C1772T polymorphism on the clinicopathological features of human esophageal squamous cell carcinoma (ESCC) remains unknown, and thus it is the main focus of our study. METHODS: The C1772T genotype of 95 ESCC patients and 104 healthy controls were studied by using the polymerase chain reaction and restriction fragment length polymorphism. Mutations were confirmed by direct DNA sequencing. The impact of C1772T on tumor size, invasive depth, lymph node metastasis, distant metastasis, histological grade and TNM stage was also studied. RESULTS: The genotype frequency observed in the patients and controls was 11.58% versus 10.58%, respectively, for genotype C/T (P > 0.05). Genotype T/T was not found in our study. Larger tumors and a higher rate of lymph node metastasis was found for the C/T group. CONCLUSIONS: Although there is no significant difference of genotype distribution between ESCC patients and healthy controls, genotype C/T is associated with larger tumor and higher rate of lymph node metastasis.