The long-term effect of bile duct injuries on health-related quality of life: a meta-analysis

Background

The reported effects of biliary injury on health-related quality of life (HRQOL) have varied widely. Meta-analysis methodology was applied to examine the collective findings of the long-term effect of bile duct injury (BDI) on HRQOL.

Methods

A comprehensive literature search was conducted in March, 2012. Because the HRQOL surveys differed among reports, BDI and uncomplicated laparoscopic cholecystectomy (LC) groups'' HRQOL scores were expressed as effect sizes (ES) in relation to a common, general population, standard. A negative ES indicated a reduced HRQOL, with a substantive reduction defined as an ES ≤ −0.50. Weighted logistic regression tested the effects of BDI (versus LC) and follow-up time on whether physical and mental HRQOL were substantively reduced.

Results

Data were abstracted from six publications, which encompass all reports of HRQOL after BDI in the current, peer-reviewed literature. The analytic database comprised 90 ES computations representing 831 patients and 11 unique study groups (six BDI and five LC). After controlling for follow-up time (P ≤ 0.001), BDI patients were more likely to have reduced long-term mental [odds ratio (OR) = 38.42, 95% confidence interval (CI) = 19.14–77.10; P < 0.001] but not physical (P = 0.993) HRQOL compared with LC patients.

Discussion

This meta-analysis of findings from six peer-review reports indicates that, in comparison to LC, there is a long-term detrimental effect of BDI on mental HRQOL.     

Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy

Background:

When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury.

Methods:

We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000–2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs.

Results:

A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000–2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and ‘others’ accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling £6 m, of which £4.3 m was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim.

Conclusions:

Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.     

Modified Cattell's pancreaticojejunostomy,buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study

Background:

Pancreatic anastomotic leak is one of the most serious complications following pancreaticoduodenectomy (PD). Various factors have been implicated as contributors to pancreatic anastomotic leaks, the incidence of which has been as high as 28% in some series.

Objectives:

We describe technical modifications to Cattell''s technique for pancreaticojejunostomy (PJ), with buttressing of ‘soft’ pancreases and use of an isolated biliopancreatic loop for reconstruction following a PD.

Methods:

We report our early experience using this technique in 50 patients who underwent PD between May 2002 and June 2006.

Results:

There was no mortality in our series. The postoperative morbidity rate was 32% (16/50), with major complications occurring in seven (14%) patients. Pancreatic leak occurred in one patient (2%) and bile leak in one patient (2%). Both patients were managed conservatively.

Conclusions:

Reconstruction after PD using an isolated biliopancreatic loop and modifications to Cattell''s technique for PJ, with buttressing of the soft pancreas, can be performed with a low risk of pancreatic anastomotic leakage.     

Patient-Reported Quality of Pain Treatment and Use of Interpreters in Spanish-Speaking Patients Hospitalized for Obstetric and Gynecological Care

BACKGROUND

Assessment and treatment of pain are based largely on patient’s self reports. Patients with limited English proficiency (LEP) may have difficulties communicating their pain symptoms in the presence of language barriers.

OBJECTIVE

To determine whether interpreter use was associated with quality of acute pain treatment among Latina patients with limited English proficiency.

DESIGN

Secondary analysis of two cross-sectional surveys.

PARTICIPANTS

One hundred and eighty-five Latino female patients hospitalized for obstetric and gynecological care who required interpreter services. Patients were classified into two groups according to interpreter availability (''Always'' and ''Not Always'' available).

MAIN MEASURES

Quality of pain treatment was measured by patient report of 1) overall level of pain control during hospitalization; 2) timeliness of pain treatment; and 3) perceived provider helpfulness to treat pain.

KEY RESULTS

Patients who always received interpreters were more likely to report higher levels of pain control (P = 0.02), timely pain treatment (P = 0.02), and greater perceived provider helpfulness to treat their pain (P = 0.005), compared with patients who not always received interpreters.

CONCLUSION

Use of interpreters by LEP patients was associated with better patient reports on quality of pain treatment, and may also improve clinical interactions related to pain.KEY WORDS: interpreters, limited English proficiency, Latinos/Latinas, pain, pain treatment     

Outcome differences across transplant centers: comparison of two methods for public reporting

Summary

Background and objectives

Reporting of standardized patient and graft survival rates by the Scientific Registry of Transplant Recipients (SRTR) aims to influence transplant centers to improve their performance. The methodology currently used is based on calculating observed-to-expected (OE) ratios for every center. Its accuracy has not been evaluated. Here, we compare the accuracy of standardized rates across centers with the OE method to an alternative generalized mixed-effect (ME) method. We also examine the association between public reporting and center outcome improvement.

Design, setting, participants, & measurements

Accuracy was measured as the root mean square error (RMSE) of the difference between standardized rates from one time period to standardized rates from a future time period. Data from the United States Renal Data System on all kidney transplants between January 1, 1996, and September 30, 2009 were analyzed.

Results

The ME method had a 0.5 to 4.5% smaller RMSE than the OE method. It also had a smaller range between the 5^th and 95^th percentile centers'' standardized rates: 7.5% versus 10.5% for 3-year graft survival and 4.7% versus 7.9% for 3-year patient survival. The range did not change after the introduction of public reporting in 2001. In addition, 33% of all deaths and 29% of all graft failures in the 3 years after transplant could be attributed to differences across centers.

Conclusions

The ME method can improve the accuracy of public reports on center outcomes. An examination of the reasons why public reports have not reduced differences across centers is necessary.     

Risk Factors for Development of Biliary Stricture in Patients Presenting with Bile Leak after Cholecystectomy

Background/Aims

This study was aimed at determining the factors associated with the development of benign biliary stricture (BBS) in patients who had sustained a bile duct injury (BDI) at cholecystectomy and developed bile leaks.

Methods

A retrospective analysis of 214 patients with BDI who were referred to our center between January 1989 and December 2009 was done.

Results

One hundred fifty-three (71%) patients developed BBS (group I), and 61 (29%) were normal (group II). By univariate analysis, female gender (p=0.02), open cholecystectomy as the index operation (p=0.0001), delay in the referral from identification of injury (p=0.04), persistence of an external biliary fistula (EBF) beyond 4 weeks (p=0.0001), EBF output >400 mL (p=0.01), presence of jaundice (p=0.0001), raised serum total bilirubin level (p=0.0001), raised serum alkaline phosphatase level (p=0.0001), and complete BDI (p=0.0001) were associated with the development of BBS. Furthermore, open cholecystectomy as the index operation (p=0.04), delayed referral (p=0.02), persistent EBF (p=0.03), and complete BDI (p=0.001) were found to predict patient outcome in the multivariate analysis.

Conclusions

For the majority of patients with BDI, the risk of developing BBS could have been predicted at the initial presentation.     

Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations

Background

Gallstones appear more frequently in patients with cirrhosis and open cholecystectomy in this patient population is associated with higher morbidity and mortality. The aim of the present study was to evaluate experience with laparoscopic cholecystectomy in patients with cirrhosis and to provide recommendations for management.

Methods

Retrospective review of laparoscopic cholecystectomy in patients with cirrhosis from March 1999 to May 2008 was performed. Peri-operative characteristics and subgroup analysis were performed in patients with Child–Pugh''s classes A, B and C cirrhosis.

Results

A total of 68 patients were reviewed in this study. In all, 69% of the patients were Child''s class A. The most common indication for cholecystectomy was chronic/symptomatic cholelithiasis (68%). Compared with patients with Child''s class B and C, laparoscopic cholecystectomy in patients with Child''s class A was associated with significantly decreased operative time (P= 0.01), blood loss (P= 0.001), conversion to open cholecystectomy (P= 0.001) and length of hospital stay (P= 0.001).

Conclusions

Laparoscopic cholecystectomy in patients with cirrhosis is feasible with no mortality and low morbidity, especially in patients with Child''s class A cirrhosis.     

Hepatic resection for post-cholecystectomy bile duct injuries: a literature review

Objectives:

This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature.

Methods:

Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair.

Results:

Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0–234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series.

Conclusions:

Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.     

Long-term outcome after early repair of iatrogenic bile duct injury. A national Danish multicentre study

Background

The aim of this retrospective study was to evaluate the peri-operative and long-term outcome after early repair with a hepaticojejunostomy (HJ).

Methods

Between 1995 and 2010, a nationwide, retrospective multi-centre study was conducted. All iatrogenic bile duct injury (BDI) sustained during a cholecystectomy and repaired with HJ in the five Hepato-Pancreatico-Biliary centres in Denmark were included.

Results

In total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. A concomitant vascular injury was identified in 26 cases (19%). Post-operative morbidity was 36% and mortality was 4%. Forty-two patients (30%) had a stricture of the HJ. The median follow-up time without stricture was 102 months. Nineteen out of the 42 patients with post-reconstruction biliary strictures had a re-HJ. Twenty-three patients were managed with percutaneous transhepatic cholangiography and dilation. The overall success rate of re-establishing the biliodigestive flow approached 93%. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation.

Conclusion

In this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of long-term complications (e.g. 30% stricture rate) and mortality in both the short- and the long-term perspective.     

Construction and Validation of a Questionnaire about Heart Failure Patients' Knowledge of Their Disease

Background

The lack of tools to measure heart failure patients'' knowledge about their syndrome when participating in rehabilitation programs demonstrates the need for specific recommendations regarding the amount or content of information required.

Objectives

To develop and validate a questionnaire to assess heart failure patients'' knowledge about their syndrome when participating in cardiac rehabilitation programs.

Methods

The tool was developed based on the Coronary Artery Disease Education Questionnaire and applied to 96 patients with heart failure, with a mean age of 60.22 ± 11.6 years, 64% being men. Reproducibility was obtained via the intraclass correlation coefficient, using the test-retest method. Internal consistency was assessed by use of Cronbach''s alpha, and construct validity, by use of exploratory factor analysis.

Results

The final version of the tool had 19 questions arranged in ten areas of importance for patient education. The proposed questionnaire had a clarity index of 8.94 ± 0.83. The intraclass correlation coefficient was 0.856, and Cronbach''s alpha, 0.749. Factor analysis revealed five factors associated with the knowledge areas. Comparing the final scores with the characteristics of the population evidenced that low educational level and low income are significantly associated with low levels of knowledge.

Conclusion

The instrument has satisfactory clarity and validity indices, and can be used to assess the heart failure patients'' knowledge about their syndrome when participating in cardiac rehabilitation programs.     

Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis

Background

Laparoscopic liver resection (LLR) is now considered a feasible alternative to open liver resection (OLR) in selected patients. Nevertheless studies comparing LLR and OLR are few and concerns remain about long-term oncological equivalence. The present study compares outcomes with LLR vs. OLR using meta-analytical methods.

Methods

Electronic literature searches were conducted to identify studies comparing LLR and OLR. Short-term outcomes evaluated included operating time, blood loss, length of hospital stay, peri-operative morbidity and resection margin status. Longer-term outcomes included local and distant recurrence, and overall (OS) and disease-free survival (DFS). Meta-analyses were performed using the Mantel–Haenszel method and Cohen''s d method, with results expressed as odds ratio (OR) or standardized mean difference (SMD), respectively, with 95% confidence intervals (CI).

Results

Twenty-six studies met the inclusion criteria with a population of 1678 patients. LLR resulted in longer operating time, but reduced blood loss, portal clamp time, overall and liver-specific complications, ileus and length of stay. No difference was found between LLR and OLR for oncological outcomes.

Discussion

LLR has short-term advantages and seemingly equivalent long-term outcomes and can be considered a feasible alternative to open surgery in experienced hands.     

Development and Validation of a Single-Item Screener for Self-Reporting Sexual Problems in U.S. Adults

Background

Brief self-assessment of sexual problems in a clinical context has the potential to improve care for patients through the ability to track trends in sexual problems over time and facilitate patient–provider communication about this important topic. However, instruments designed for research are typically too long to be practical in clinical practice.

Objective

To develop and validate a single-item self-report clinical screener that would capture common sexual problems and concerns for men and women.

Design

We created three candidate screener items, refined them through cognitive interviews, and administered them to a large sample. We compared the prevalence of responses to each item and explored the discrepancies between items. We evaluated the construct validity of the items by comparing them to scores on the Patient-Reported Outcomes Measurement Information System® Sexual Function and Satisfaction (PROMIS® SexFS) measure.

Participants

Local patients participated in two rounds of cognitive interviews (n = 7 and n = 11). A probability-based random sample of U.S. adults comprised the item-testing sample (n = 3517).

Main Measures

The items were as follows: 1) a yes/no item on any sexual problems or concerns (“general screener”), 2) a yes/no item on problems experienced for 3 months or more during the past 12 months, with a list of examples (“long list screener”), and 3) an item identical to the long list screener except that examples appeared individually as response options and respondents could check all that applied (“checklist screener”).

Key Results

All of the screeners tested showed evidence for basic validity and had minimal missing data. Percentages of women and men endorsing the screeners were 10 % and 15 % (general); 20 % and 17 % (long list); and 38 % and 30 % (checklist), respectively. Participants who endorsed the screeners had lower function compared to those who did not endorse them.

Conclusions

We recommend the checklist screener for its specificity and ability to identify specific problems associated with decreased sexual function.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3333-3) contains supplementary material, which is available to authorized users.     

Computerized Algorithms: Safety and Effectiveness of a Computerized Subcutaneous Insulin Program to Treat Inpatient Hyperglycemia

Background

This proof of concept study was designed to evaluate the safety and effectiveness of a computerized insulin program, the Clarian GlucoStabilizer™ Subcutaneous Insulin Program (CGS-SQ). This paper discusses the CGS-SQ''s impact on the glycemic control of hospitalized patients with hyperglycemia.

Methods

Patients at Methodist and Indiana University Hospitals requiring subcutaneous insulin were treated using the CGS-SQ. This program calculates subcutaneous bolus insulin doses based on the current blood glucose (BG), using an insulin sensitivity factor, the number of grams of carbohydrates eaten, and an insulin-to-carbohydrate ratio, with a goal of maintaining the patient''s BG in a prespecified target range. The target range, insulin sensitivity factor, and insulin-to-carbohydrate ratio are established by the physician.

Results

From April 2006 to September 2007, the CGS-SQ treated 1772 patients at Methodist and Indiana University Hospitals, with 46,575 BGs in its database. For these patients, the average BG was 158.3 mg/dl, 40.5% percent of BGs were in the default target range of 100–150 mg/dl, and 69.8% were in the wider range of 70–180 mg/dl. The hypoglycemia (BG <40 mg/dl) rate was 0.18%.

Conclusions

The CGS-SQ provided a means to deliver insulin in a standardized manner, resulting in satisfactory BG control with a low hypoglycemia rate, thus serving as a tool for safe and effective insulin therapy for hospitalized patients.     

A comparison of the spatial dependence of body mass index among adults and children in a Swiss general population

Background:

Body mass index (BMI) may cluster in space among adults and be spatially dependent. Whether BMI clusters among children and how age-specific BMI clusters are related remains unknown. We aimed to identify and compare the spatial dependence of BMI in adults and children in a Swiss general population, taking into account the area''s income level.

Methods:

Geo-referenced data from the Bus Santé study (adults, n=6663) and Geneva School Health Service (children, n=3601) were used. We implemented global (Moran''s I) and local (local indicators of spatial association (LISA)) indices of spatial autocorrelation to investigate the spatial dependence of BMI in adults (35–74 years) and children (6–7 years). Weight and height were measured using standardized procedures. Five spatial autocorrelation classes (LISA clusters) were defined including the high–high BMI class (high BMI participant''s BMI value correlated with high BMI-neighbors'' mean BMI values). The spatial distributions of clusters were compared between adults and children with and without adjustment for area''s income level.

Results:

In both adults and children, BMI was clearly not distributed at random across the State of Geneva. Both adults'' and children''s BMIs were associated with the mean BMI of their neighborhood. We found that the clusters of higher BMI in adults and children are located in close, yet different, areas of the state. Significant clusters of high versus low BMIs were clearly identified in both adults and children. Area''s income level was associated with children''s BMI clusters.

Conclusions:

BMI clusters show a specific spatial dependence in adults and children from the general population. Using a fine-scale spatial analytic approach, we identified life course-specific clusters that could guide tailored interventions.     

Adding New Tools to the Black Bag—Introduction of Ultrasound into the Physical Diagnosis Course

INTRODUCTION

Ultrasound, a versatile diagnostic modality that permits real-time visualization at the patient’s bedside, can be used as an adjunct in teaching physical diagnosis (PD). Aims: (1) to study the feasibility of incorporating ultrasound into PD courses and (2) determine whether learners can demonstrate image recognition and acquisition skills.

PROGRAM DESCRIPTION

Three hundred seven second-year medical students were introduced to cardiovascular and abdominal ultrasound scanning after training in the physical examination. This consisted of a demonstration of the ultrasound examination, followed by practice on standardized patients (SPs). Pre-post tests were administered to evaluate students’ knowledge and understanding of ultrasound. Students performed an ultrasound examination during the PD final examination.

PROGRAM EVALUATION

Pre-post test data revealed significant improvements in image recognition. On the final exam, the highest scores (98.4%) were obtained for the internal jugular vein and lowest scores (74.6%) on the Focused Assessment with Sonography for Trauma images. Eighty-nine percent of students’ surveyed felt ultrasound was a valuable tool for physicians.

DISCUSSION

An introductory ultrasound course is effective in improving medical students'' acquisition and recognition of basic cardiovascular and abdominal ultrasound images. This innovative program demonstrates the feasibility of incorporating portable ultrasound as a learning tool during medical school.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-010-1451-5) contains supplementary material, which is available to authorized users.KEY WORDS: ultrasound, medical education, physical diagnosis     

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography

Background

Endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis.

Methods

The study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES).

Results

The PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79–9.91)] and more complex [higher than 6 points, on a 0–10 scale, OR 3.12 (95% CI 1.43–6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different.

Discussion

A laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.     

Anticoagulation policy after venous resection with a pancreatectomy: a systematic review

Background

Portal vein (PV) resection is used increasingly in pancreatic resections. There is no agreed policy regarding anticoagulation.

Methods

A systematic review was performed to compare studies with an anticoagulation policy (AC+) to no anticoagulation policy (AC−) after venous resection.

Results

There were eight AC+ studies (n = 266) and five AC− studies (n = 95). The AC+ studies included aspirin, clopidogrel, heparin or warfarin. Only 50% of patients in the AC+ group received anticoagulation. There were more prosthetic grafts in the AC+ group (30 versus 2, Fisher''s exact P < 0.001). The overall morbidity and mortality was similar in both groups. Early PV thrombosis (EPVT) was similar in the AC+ group and the AC− group (7%, versus 3%, Fisher''s exact P = 0.270) and was associated with a high mortality (8/20, 40%). When prosthetic grafts were excluded there was no difference in the incidence of EPVT between both groups (1% vs 2%, Fisher''s exact test P = 0.621).

Conclusion

There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts.     

Cow's Milk Allergy among Children with Gastroesophageal Reflux Disease

Background/Aims

Gastroesophageal reflux disease (GERD) and cow''s milk allergy (CMA) are two common conditions that occur in infancy. This study was performed to investigate the frequency of CMA in a group of patients with GERD.

Methods

Eighty-one children with signs and symptoms of GERD were enrolled in this study. All subjects received omeprazole for 4 weeks after the initial evaluation. Empirical elimination of cow''s milk from the diet was started for the patients who did not respond to the omeprazole treatment.

Results

Seventy-two cases presented with gastrointestinal signs and symptoms, whereas the remaining nine cases presented with respiratory complaints. After the initial treatment with omeprazole, two thirds of the cases (54 patients, 66.7%) responded well, and all of their symptoms were resolved. Cow''s milk was eliminated from the diets of the remaining 27 patients. All signs and symptoms of GERD were resolved in this group after a 4 week elimination of cow''s milk from the diet.

Conclusions

A diagnosis of CMA was considered in one third of the pediatric cases with signs and symptoms of GERD. This finding shows that CMA can mimic or aggravate all signs and symptoms of severe GERD during infancy.     

Rapamycin Enhances HBV Production by Inducing Cellular Autophagy

Background:

Some reports revealed that rapamycin could reactivate HBV infection. However, the mechanism has not been clearly explained.

Objectives:

In this report, we studied the mechanism by which rapamycin enhances HBV replication and expression by inducing cellular autophagy.

Materials and Methods:

HepG2.2.15 cells were treated with rapamycin to induce autophagy. Autophagosomes were observed by fluorescence microscopy and transmission electron microscopy. Autophagy marker protein LC3-Ⅱ/LC3-Ⅰwas detected by Western blotting. HBV DNA and mRNA were determined by real time PCR and Southern blotting. HBsAg was evaluated by ELISA.

Results:

In HepG2.2.15 cells, HBV DNA and HBsAg increased when host cells were treated with rapamycin and the effect was reversed by autophagy inhibitor, 3-methyladenine (3-MA).

Conclusions:

These results indicated a potential explanation for reactivation of HBV infection when patients with hepatitis receive rapamycin.     

The feasibility and safety of the endoscopic submucosal dissection of superficial gastric neoplastic lesions in patients with compensated liver cirrhosis: a retrospective study

Background/Aims

When undergoing endoscopic submucosal dissection (ESD), patients with liver cirrhosis (LC) may suffer from a high risk of bleeding, bacteremia and tissue vulnerability. There have been few reports evaluating the efficacy and safety of ESD in patients with LC.

Methods

From January 2004 to March 2010, 23 patients with LC (cirrhosis group) underwent ESD for superficial gastric neoplastic lesions. The number of patients with a liver function in the Child-Pugh classes A and B were 20 and 3, respectively. The clinical outcomes and complications were compared with 69 patients without LC (control group) that were matched for age and sex.

Results

The en bloc resection, R0 resection and en bloc plus R0 resection rates of the cirrhosis group were 82.6%, 91.3%, and 82.6%, respectively, and did not show significant differences from the rates of the control group. No local recurrence was found in either group during the follow-up period. The procedure length of time (41.0 vs 39.0 minutes), rate of bleeding (4.3% vs 7.2%) and rate of perforation (0.0% vs 1.4%) in the cirrhosis group were also comparable to the results from the control group.

Conclusions

ESD was safely performed in patients with LC, and satisfactory outcomes were achieved with high en bloc and R0 resection rates for superficial gastric neoplastic lesions.