Outcome and costs of laparoscopic pancreaticoduodenectomy during the initial learning curve vs laparotomy

AIM:To compare laparoscopic pancreaticoduodenectomy(TLPD) during the initial learning curve with open pancreaticoduodenectomy in terms of outcome and costs.METHODS:This is a retrospective review of the consecutive patients who underwent TLPD between December 2009 and April 2014 at our institution.The experiences of the initial 15 consecutive TLPD cases,considered as the initial learning curve of each surgeon,were compared with the same number of consecutive laparotomy cases with the same spectrum of diseases in terms of outcome and costs.Laparoscopic patients with conversion to open surgery were excluded.Preoperative demographic and comorbidity data were obtained.Postoperative data on intestinal movement,pain score,mortality,complications,and costs were obtained for analysis.Complications related to surgery included pneumonia, intra-abdominal abscess,postpancreatectomy hemorrhage,biliary leak,pancreatic fistula,delayed gastric emptying,and multiple organ dysfunction syndrome.The total costs consisted of cost of surgery,anesthesia,and admission examination.RESULTS:A total of 60 patients,including 30 consecutive laparoscopic cases and 30 consecutive open cases,were enrolled for review.Demographic and comorbidity characteristics of the two groups were similar.TLPD required a significantly longer operative time(513.17 ± 56.13 min vs 371.67 ± 85.53 min,P 0.001).The TLPD group had significantly fewer mean numbers of days until bowel sounds returned(2.03 ± 0.55 d vs 3.83 ± 0.59 d,P 0.001) and exhaustion(4.17 ± 0.75 d vs 5.37 ± 0.81 d,P 0.001).The mean visual analogue score on postoperative day 4 was less in the TLPD group(3.5 ± 9.7 vs 4.47 ± 1.11,P 0.05).No differences in surgery-related morbidities and mortality were observed between the two groups.Patients in the TLPD group recovered more quickly and required a shorter hospital stay after surgery(9.97 ± 3.74 d vs 11.87 ± 4.72 d,P 0.05).A significant difference in the total cost was found between the two groups(TLPD 81317.43 ± 2027.60 RMB vs laparotomy 78433.23 ± 5788.12 RMB,P 0.05).TLPD had a statistically higher cost for both surgery(24732.13 ± 929.28 RMB vs 19317.53 ± 795.94 RMB,P 0.001)and anesthesia(6192.37 ± 272.77 RMB vs 5184.10 ± 146.93 RMB,P 0.001),but a reduced cost for admission examination(50392.93 ± 1761.22 RMB vs 53931.60 ± 5556.94 RMB,P 0.05).CONCLUSION:TLPD is safe when performed by experienced pancreatobiliary surgeons during the initial learning curve,but has a higher cost than open pancreaticoduodenectomy.     

Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

AIM:To compare the outcomes between doubleguidewire technique(DGT) and transpancreatic precut sphincterotomy(TPS) in patients with difficult biliary cannulation.METHODS:This was a prospective,randomized study conducted in single tertiary referral hospital in Korea.Between January 2005 and September 2010.A total of 71 patients,who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved,were randomized into DGT(n = 34) and TPS(n = 37) groups.DGT or TPS was done for selective biliary cannulation.We measured the technical success rates of biliary cannulation,median cannulation time,and procedure related complications.RESULTS:The distribution of patients after randomization was balanced,and both groups were comparable in baseline characteristics,except the higher percentage of endoscopic nasobiliary drainage in the DGT group(55.9% vs 13.5%,P < 0.001).Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min,P = 0.732,respectively.There was no significant difference between the two groups.The overall incidence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis was 38.2% vs 10.8%,P < 0.011 in the DGT group and the TPS group;post-procedure pancreatitis was significantly higher in the DGT group.But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups;DGT group vs TPS group:14.7% vs 16.2%,P < 1.0.CONCLUSION:When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved,DGT and TPS facilitated biliary cannulation and showed similar success rates.However,post-procedure pancreatitis was significantly higher in the DGT group.     

IGF2 differentially methylated region hypomethylation in relation to pathological and molecular features of serrated lesions

AIM:To investigate insulin-like growth factor 2(IGF2)differentially methylated region(DMR)0 hypomethylation in relation to clinicopathological and molecular features in colorectal serrated lesions.METHODS:To accurately analyze the association between the histological types and molecular features of each type of serrated lesion,we consecutively collected1386 formalin-fixed paraffin-embedded tissue specimens that comprised all histological types[hyperplastic polyps(HPs,n=121),sessile serrated adenomas(SSAs,n=132),traditional serrated adenomas(TSAs,n=111),non-serrated adenomas(n=195),and colorectal cancers(n=827)].We evaluated the methylation levels of IGF2 DMR0 and long interspersed nucleotide element-1(LINE-1)in HPs(n=115),SSAs(n=120),SSAs with cytological dysplasia(n=10),TSAs(n=91),TSAs with high-grade dysplasia(HGD)(n=15),non-serrated adenomas(n=80),non-serrated adenomas with HGD(n=105),and CRCs(n=794).For the accurate quantification of the relative methylation levels(scale 0%-100%)of IGF2 DMR0 and LINE-1,we used bisulfite pyrosequencing method.Tumor specimens were analyzed for microsatellite instability,KRAS(codons 12 and 13),BRAF(V600E),and PIK3CA(exons 9and 20)mutations;MLH1 and MGMT methylation;and IGF2 expression by immunohistochemistry.RESULTS:The distribution of the IGF2 DMR0 methylation level in 351 serrated lesions and 185 non-serrated adenomas(with or without HGD)was as follows:mean61.7,median 62.5,SD 18.0,range 5.0-99.0,interquartile range 49.5-74.4.The IGF2 DMR0 methylation level was divided into quartiles(Q1≥74.5,Q2 62.6-74.4,Q3 49.6-62.5,Q4≤49.5)for further analysis.With regard to the histological type,the IGF2 DMR0 methylation levels of SSAs(mean±SD,73.1±12.3)were significantly higher than those of HPs(61.9±20.5),TSAs(61.6±19.6),and non-serrated adenomas(59.0±15.8)(P<0.0001).The IGF2 DMR0 methylation level was inversely correlated with the IGF2 expression level(r=-0.21,P=0.0051).IGF2 DMR0 hypomethylation was less frequently detected in SSAs compared with HPs,TSAs,and non-serrated adenomas(P<0.0001).Multivariate logistic regression analysis also showed that IGF2 DMR0 hypomethylation was inversely associated with SSAs(P<0.0001).The methylation levels of IGF2 DMR0 and LINE-1 in TSAs with HGD(50.2±18.7and 55.7±5.4,respectively)were significantly lower than those in TSAs(61.6±19.6 and 58.8±4.7,respectively)(IGF2 DMR0,P=0.038;LINE-1,P=0.024).CONCLUSION:IGF2 DMR0 hypomethylation may be an infrequent epigenetic alteration in the SSA pathway.Hypomethylation of IGF2 DMR0 and LINE-1 may play a role in TSA pathway progression.     

Melatonin attenuates acute pancreatitis-associated lung injury in rats by modulating interleukin 22

AIM:To investigate whether therapeutic treatment with melatonin could protect rats against acute pancreatitis and its associated lung injury.METHODS:Seventy-two male Sprague-Dawley rats were randomly divided into three groups:the sham operation(SO),severe acute pancreatitis(SAP),and melatonin treatment(MT) groups.Acute pancreatitis was induced by infusion of 1 mL/kg of sodium taurocholate(4% solution) into the biliopancreatic duct.Melatonin(50 mg/kg) was administered 30 min before pancreatitis was induced,and the severity of pancreatic and pulmonary injuries was evaluated 1,4 and 8 h after induction.Serum samples were collected to measure amylase activities,and lung tissues were removed to measure levels of mRNAs encoding interleukin 22(IL-22) and T helper cell 22(Th22),as well as levels of IL-22.RESULTS:At each time point,levels of mRNAs encoding IL-22 and Th22 were significantly higher(P 0.001) in the MT group than in the SAP group(0.526 ± 0.143 vs 0.156 ± 0.027,respectively,here and throughout,after 1 h;0.489 ± 0.150 vs 0.113 ± 0.014 after 4 h;0.524 ± 0.168 vs 0.069 ± 0.013 after 8 h,0.378 ± 0.134 vs 0.122 ± 0.015 after 1 h;0.205 ± 0.041 vs 0.076 ± 0.019 after 4 h;0.302 ± 0.108 vs 0.045 ± 0.013 after 8 h,respectively) and significantly lower(P 0.001) in the SAP group than in the SO group(0.156 ± 0.027 vs 1.000 ± 0.010 after 1 h;0.113 ± 0.014 vs 1.041 ± 0.235 after 4 h;0.069 ± 0.013 vs 1.110 ± 0.213 after 8 h,0.122 ± 0.015 vs 1.000 ± 0.188 after 1 h;0.076 ± 0.019 vs 0.899 ± 0.125 after 4 h;0.045 ± 0.013 vs 0.991 ± 0.222 after 8 h,respectively).The mean pathological scores for pancreatic tissues in the MT group were significantly higher(P 0.01) than those for samples in the SO group(1.088 ± 0.187 vs 0.488 ± 0.183 after 1 h;2.450 ± 0.212 vs 0.469 ± 0.242 after 4 h;4.994 ± 0.184 vs 0.513 ± 0.210 after 8 h),but were significantly lower(P 0.01) than those for samples in the SAP group at each time point(1.088 ± 0.187 vs 1.969 ± 0.290 after 1 h;2.450 ± 0.212 vs 3.344 ± 0.386 after 4 h;4.994 ± 0.184 vs 6.981 ± 0.301 after 8 h).The severity of SAP increased significantly(P 0.01) over time in the SAP group(1.088 ± 0.187 vs 2.450 ± 0.212 between 1 h and 4 h after inducing pancreatitis;and 2.450 ± 0.212 vs 4.994 ± 0.184 between 4 and 8 h after inducing pancreatitis).CONCLUSION:Melatonin protects rats against acute pancreatitis-associated lung injury,probably through the upregulation of IL-22 and Th22,which increases the innate immunity of tissue cells and enhances their regeneration.     

Increase in serum bilirubin levels in obstructive jaundice secondary to pancreatic and periampullary malignancy--implications for timing of resectional surgery and use of biliary drainage

Background. Routine preoperative biliary drainage in cases of jaundice secondary to pancreatobiliary malignancy is associated with a significant risk of complications, failure and stent occlusion. It may be possible to avoid biliary drainage in those patients who are not deeply jaundiced. Aims. To measure presenting serum bilirubin and its rate of increase in patients with malignant obstructive jaundice. To predict the urgency with which surgery should be performed to avoid preoperative biliary drainage. Patients and methods. Prospective data collection for all pancreatic and periampullary malignancies over a period of 18 months was carried out. Serum bilirubin levels before successful drainage were recorded. Rates of increase in bilirubin and the number of days for bilirubin to reach different thresholds were calculated. Results. Of 111 patients, 66 (59%) had resectable disease on imaging investigations. Median serum bilirubin on presentation was 160 µmol/l. Median increase was 13.1 µmol/l/day or approximately 100 µmol/l/week. The predicted number of days for bilirubin levels to reach a variety of thresholds varied significantly. For a patient presenting with a serum bilirubin of 160 µmol/l, the mean number of days for it to rise to 200 µmol/l, 300 µmol/l, 400 µmol/l and 500 µmol/l was 3, 13, 22 and 31 days, respectively. Conclusions. There is a variable window of opportunity in jaundiced patients with pancreatic and periampullary malignancy during which surgery may be performed to avoid biliary drainage procedures, depending on the threshold for operating on the jaundiced patient.     

High dose glargine alters the expression profiles of microRNAs in pancreatic cancer cells

AIM: To investigate the effect of high dose glargine on the expression profiles of microRNAs in human pancreatic cancer cells.METHODS: Real-time polymerase chain reaction array (RT-PCR) was applied to investigate miRNAs differentially expressed in Sw1990 cells treated with or without 100 IU/L glargine. Stem-loop RT-PCR was used to confirm the results of the array assay in Sw1990 and Panc-1 cells. The effects of miR-95 on cell growth, apoptosis, invasion and migration abilities were respectively examined by CCK8 assay, apoptosis assay, Matrigel invasion and migration assay in Sw1990 and Panc-1 cells. Nude mice xenograft models with Sw1990 cells were built to investigate pancreatic cancer growth in vivo after transfection by the lentivirus pGLV3-GFP- miR-95.RESULTS: Ten miRNAs were significantly up-regulated and 2 miRNAs down-regulated in glargine treated Sw1990 cells when compared with non-treated cells (2.48-fold changes on average, P < 0.01). miR-95, miR-134 and miR-34c-3p are the top three miRNAs regulated by glargine (3.65-fold, 2.67-fold and 2.60-fold changes respectively, P < 0.01) in Sw1990 cells. Stem-loop RT-PCR confirmed that high dose glargine up-regulated the expression of miR-95 and miR-134 in both Sw1990 and Panc-1 cells. The most obvious change is the apparent increase of miR-95. Forced expression of miR-95 significantly increased cell proliferation (Sw1990: 2.510 ± 0.129 vs 2.305 ± 0.187, P < 0.05; Panc-1: 2.439 ± 0.211 vs 2.264 ± 0.117, P < 0.05), invasion (Sw1990: 67.90 ± 12.33 vs 47.30 ± 5.89, P < 0.01; Panc-1: 37.80 ± 8.93 vs 30.20 ± 5.14, P < 0.01), migration (Sw1990: 101 ± 6.00 vs 51.20 ± 8.34, P < 0.01; Panc-1: 91.80 ± 9.22 vs 81.50 ± 7.47, P < 0.01) and inhibited cell apoptosis (Sw1990: 22.05% ± 1.92% vs 40.32% ± 1.93%, P < 0.05; Panc-1: 20.17% ± 0.85% vs 45.60% ± 1.43%, P < 0.05) when compared with paired negative controls, whereas knockdown of miR-95 obtained the opposite effect. Nude mice xenograft models confirmed that miR-95 promoted the growth of pancreatic cancer in vivo when compared with negative control (tumor volume: 373.82 ± 23.67 mL vs 219.69 ± 17.82 mL, P < 0.05).CONCLUSION: These observations suggested that modulation of miRNA expression may be an important mechanism underlying the biological effects of glargine.     

Roles of BN52021 in platelet-activating factor pathway in inflammatory MS1 cells

AIM: To determine the effects of BN52021 on platelet-activating factor receptor (PAFR) signaling molecules under lipopolysaccharide (LPS)-induced inflammatory conditions in MS1 cells. METHODS: MS1 cells (a mouse pancreatic islet endothelial cell line) were grown in Dulbecco’s modified Eagle’s medium supplemented with 10% fetal bovine serum, 2 mmol/L glutamine and 100 μg/mL penicillin/streptomycin in 5% CO 2 at 37 ℃. After growth to confluency in media, the cells were processed for subsequent studies. The MS1 cells received 0, 0.1, 1 and 10 μg/mL LPS in this experiment. The viability/prolifera-tion of the cells induced by LPS was observed using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide colorimetric assay. Apoptosis and necrosis of the cells under the inflammatory condition described previously were observed using Hoechst 33342-propidium iodide staining. Adenylate cyclase (AC), phospholipase A 2 (PLA 2 ), phospholipase Cβ (PLCβ), protein tyrosine kinase (PTK), G protein-coupled receptor kinases (GRK) and p38-mitogen-activated protein kinase (p38 MAPK) mRNA in the PAFR signaling pathway were measured by real-time polymerase chain reaction. The protein expression level of phosphorylated AC (p-AC), phosphorylated PLA 2 (p-PLA 2 ), phosphorylated PTK (p-PTK), phosphorylated p38 MAPK (p-p38 MAPK), PLCβ and GRK was measured using Western blotting analysis. RESULTS: The activity of MS1 cells incubated with dif- ferent concentrations of LPS for 6 h decreased significantly in the 1 μg/mL LPS group (0.49 ± 0.10 vs 0.67 ± 0.13, P < 0.05) and 10 μg/mL LPS group (0.44 ± 0.10 vs 0.67 ± 0.13, P < 0.001), but not in 0.1 μg/mL group. When the incubation time was extended to 12 h (0.33 ± 0.05, 0.32 ± 0.03 and 0.25 ± 0.03 vs 0.69 ± 0.01) and 24 h (0.31 ± 0.01, 0.29 ± 0.03 and 0.25 ± 0.01 vs 0.63 ± 0.01), MS1 cell activity decreased in all LPS concentration groups compared with the blank control (P < 0.001). BN52021 significantly improved the cell activity when its concentration     

Gastrojejunostomy in patients with unresectable pancreatic head cancer - the use of Roux loop significantly shortens the hospital length of stay

AIM:To evaluate the use of the Roux loop on the postoperative course in patients submitted for gastroenteroanastomosis(GE).METHODS:Non-jaundiced patients(n=41)operated on in the Department of General and Transplant Surgery in Lodz,between January 2010 and December 2011 were enrolled.The tumor was considered unresectable when liver metastases or major vascular involvement were confirmed.Patients were randomized to receive Roux(n=21)or conventional GE(n=20)on a prophylactic basis.RESULTS:The mean time to nasogastric tube withdrawal in Roux GE group was shorter(1.4±0.75 vs2.8±1.1,P<0.001).Time to starting oral liquids,soft diet and regular diet were decreased(2.3±0.86 vs 3.45±1.19;P<0.001;3.3±0.73 vs 4.4±1.23,P<0.001and 4.5±0.76 vs 5.6±1.42,P=0.002;respectively).The Roux GE group had a lower use of prokinetics(10mg thrice daily for 2.2±1.8 d vs 3.7±2.6 d,P=0.044;total 62±49 mg vs 111±79 mg,P=0.025).The mean hospitalization time following Roux GE was shorter(7.7 d vs 9.6 d,P=0.006).Delayed gastric emptying(DGE)was confirmed in 20%after conventional GE but in none of the patients following Roux GE.CONCLUSION:Roux gastrojejunostomy during open abdomen exploration in patients with unresectable pancreatic cancer is easy to perform,decreases the incidence of DGE and lowers hospitalization time.     

Effects of Lactobacillus plantarum on gut barrier function in experimental obstructive jaundice

AIM: To investigate the mechanisms of Lactobacillus plantarum (L. plantarum) action on gut barrier in preoperative and postoperative experimental obstructive jaundice in rats.METHODS: Forty rats were randomly divided into groups of sham-operation, bile duct ligation (BDL), BDL + L. plantarum, BDL + internal biliary drainage (IBD), and BDL + IBD + L. plantarum. Ten days after L. plantarum administration, blood and ileal samples were collected from the rats for morphological examination, and intestinal barrier function, liver function, intestinal oxidative stress and protein kinase C (PKC) activity measurement. The distribution and expression of the PKC and tight junction (TJ) proteins, such as occludin, zonula occludens-1, claudin-1, claudin-4, junction adhesion molecule-A and F-actin, were examined by confocal laser scanning microscopy, immunohistochemistry, Western blotting, real-time fluorescent quantitative polymerase chain reaction assay.RESULTS: L. plantarum administration substantially restored gut barrier, decreased enterocyte apoptosis, improved intestinal oxidative stress, promoted the activity and expression of protein kinase (BDL vs BDL + L. plantarum, 0.295 ± 0.007 vs 0.349 ± 0.003, P < 0.05; BDL + IBD vs BDL + IBD + L. plantarum, 0.407 ± 0.046 vs 0.465 ± 0.135, P < 0.05), and particularly enhanced the expression and phosphorylation of TJ proteins in the experimental obstructive jaundice (BDL vs BDL + L. plantarum, 0.266 ± 0.118 vs 0.326 ± 0.009, P < 0.05). The protective effect of L. plantarum was more prominent after internal biliary drainage ( BDL + IBD vs BDL + IBD + L. plantarum, 0.415 ± 0.105 vs 0.494 ± 0.145, P < 0.05).CONCLUSION: L. plantarum can decrease intestinal epithelial cell apoptosis, reduce oxidative stress, and prevent TJ disruption in biliary obstruction by activating the PKC pathway.     

Prevalence of functional dyspepsia and its subgroups in patients with eating disorders

AIM: To study the prevalence of functional dyspepsia (FD) (Rome III criteria) across eating disorders (ED), obese patients, constitutional thinner and healthy volunteers.METHODS: Twenty patients affected by anorexia nervosa, 6 affected by bulimia nervosa, 10 affected by ED not otherwise specified according to diagnostic and statistical manual of mental disorders, 4th edition, nine constitutional thinner subjects and, thirty-two obese patients were recruited from an outpatients clinic devoted to eating behavior disorders. Twenty-two healthy volunteers matched for age and gender were enrolled as healthy controls. All participants underwent a careful clinical examination. Demographic and anthropometric characteristics were obtained from a structured questionnaires. The presence of FD and, its subgroups, epigastric pain syndrome and postprandial distress syndrome (PDS) were diagnosed according to Rome III criteria. The intensity-frequency score of broader dyspeptic symptoms such as early satiety, epigastric fullness, epigastric pain, epigastric burning, epigastric pressure, belching, nausea and vomiting were studied by a standardized questionnaire (0-6). Analysis of variance and post-hoc Sheffè tests were used for comparisons.RESULTS: 90% of patients affected by anorexia nervosa, 83.3% of patients affected by bulimia nervosa, 90% of patients affected by ED not otherwise specified, 55.6% of constitutionally thin subjects and 18.2% healthy volunteers met the Postprandial Distress Syndrome Criteria (χ², P < 0.001). Only one bulimic patient met the epigastric pain syndrome diagnosis. Postprandial fullness intensity-frequency score was significantly higher in anorexia nervosa, bulimia nervosa and ED not otherwise specified groups compared to the score calculated in the constitutional thinner group (4.15 ± 2.08 vs 1.44 ± 2.35, P = 0.003; 5.00 ± 2.45 vs 1.44 ± 2.35, P = 0.003; 4.10 ± 2.23 vs 1.44 ± 2.35, P = 0.002, respectively), the obese group (4.15 ± 2.08 vs 0.00 ± 0.00, P < 0.001; 5.00 ± 2.45 vs 0.00 ± 0.00, P < 0.001; 4.10 ± 2.23 vs 0.00 ± 0.00, P < 0.001, respectively) and healthy volunteers (4.15 ± 2.08 vs 0.36 ± 0.79, P < 0.001; 5.00 ± 2.45 vs 0.36 ± 0.79, P < 0.001; 4.10 ± 2.23 vs 0.36 ± 0.79, P < 0.001, respectively). Early satiety intensity-frequency score was prominent in anorectic patients compared to bulimic patients (3.85 ± 2.23 vs 1.17 ± 1.83, P = 0.015), obese patients (3.85 ± 2.23 vs 0.00 ± 0.00, P < 0.001) and healthy volunteers (3.85 ± 2.23 vs 0.05 ± 0.21, P < 0.001). Nausea and epigastric pressure were increased in bulimic and ED not otherwise specified patients. Specifically, nausea intensity-frequency-score was significantly higher in bulimia nervosa and ED not otherwise specified patients compared to anorectic patients (3.17 ± 2.56 vs 0.89 ± 1.66, P = 0.04; 2.70 ± 2.91 vs 0.89 ± 1.66, P = 0.05, respectively), constitutional thinner subjects (3.17 ± 2.56 vs 0.00 ± 0.00, P = 0.004; 2.70 ± 2.91 vs 0.00 ± 0.00, P = 0.005, respectively), obese patients (3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001; 3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001 respectively) and, healthy volunteers (3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.002; 3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.001, respectively). Epigastric pressure intensity-frequency score was significantly higher in bulimic and ED not otherwise specified patients compared to constitutional thin subjects (4.67 ± 2.42 vs 1.22 ± 1.72, P = 0.03; 4.20 ± 2.21 vs 1.22 ± 1.72, P = 0.03, respectively), obese patients (4.67 ± 2.42 vs 0.75 ± 1.32, P = 0.001; 4.20 ± 2.21 vs 0.75 ± 1.32, P < 0.001, respectively) and, healthy volunteers (4.67 ± 2.42 vs 0.67 ± 1.46, P = 0.001; 4.20 ± 2.21 vs 0.67 ± 1.46, P = 0.001, respectively). Vomiting was referred in 100% of bulimia nervosa patients, in 20% of ED not otherwise specified patients, in 15% of anorexia nervosa patients, in 22% of constitutional thinner subjects, and, in 5.6% healthy volunteers (χ², P < 0.001).CONCLUSION: PDS is common in eating disorders. Is it mandatory in outpatient gastroenterological clinics to investigate eating disorders in patients with PDS?     

Prospective controlled study on the effects of polyethylene glycol in capsule endoscopy

AIM: To prospectively confirm whether a small amount of polyethylene glycol (PEG) ingested after swallowing endoscopy capsule improves image quality and completion rate.METHODS: Forty-four consecutive patients referred to us for capsule endoscopy (CE) were randomized to two groups. All patients were restricted to clear fluids for 12 h before the examination. Patients in group A (22 cases) received no additional preparation, while those in group B (20 cases) ingested 500 mL of PEG within a 2 h period starting 30 min after swallowing the capsule. Clear fluids and meals were allowed 2 h and 4 h after capsule ingestion, respectively. Image quality was assessed as the percentage of visualized bowel surface area as follows: 1: < 25%; 2: 25%-49%; 3: 50%-74%; 4: 75%-89%; 5: > 90%. The small bowel record was divided into five segments by time, and the score for each segment was evaluated. All CE examinations were performed with the Pillcam SB capsule endoscopy system (Given Imaging Co. Ltd., Yoqnem).RESULTS: This study ended in December 2009, because sample size was considered large enough. A total of 44 patients were enrolled. Two patients in group B were excluded from the analysis because small bowel images could not be obtained from these patients; one had a full stomach, while the other presented with a massive gastric bleed. Thus, 22 patients from group A and 20 patients from group B completed the study. There was no significant difference in age (P = 0.22), sex (P = 0.31), and indication for CE. No significant adverse events occurred in any of the study patients. In group A, image quality deteriorated as the capsule progressed distally. However, in group B, image quality was maintained to the distal small bowel. In each of the five segments, the visibility score was significantly higher in group B than in group A (segment 1: 4.3 ± 0.7 vs 4.7 ± 0.5, P = 0.03; segment 2: 4.2 ± 0.9 vs 4.8 ± 0.4, P = 0.01; segment 3: 4.0 ± 1.0 vs 4.6 ± 0.7, P = 0.04; segment 4: 3.6 ± 1.1 vs 4.5 ± 0.6, P = 0.003; segment 5: 2.7 ± 1.0 vs 4.4 ± 0.8, P = 0.00004). Thus, the use of PEG during CE examination significantly improved image quality in all time segments, and this effect was more pronounced in the distal ileum. The completion rate to the cecum was not significantly different between groups A and B (81.8% vs 85.0%, P = 0.89). There was no difference in the gastric transit time between groups (36.2 ± 35.0 min vs 54.0 ± 56.6 min, P = 0.23), but the small bowel transit time was significantly longer in group A than in group B (246.0 ± 107.0 min vs 171.0 ± 104.0 min, P = 0.04).CONCLUSION: The ingestion of a small amount of PEG after the swallowing of an endoscopy capsule significantly improved CE image quality, but did not enhance the completion rate to the cecum.     

Expression profile of polyunsaturated fatty acids in colorectal cancer

AIM:To investigate the relationship between the metabolism of polyunsaturated fatty acids(PUFAs)andtumor-associated factors for predicting the outcome of colorectal carcinoma(CRC)in Chinese patients.METHODS:Fresh-frozen malignant and normal tissues from 82 Chinese patients with CRC were analyzed for PUFA composition using gas-liquid chromatography.The levels of vascular endothelial growth factor(VEGF),cyclooxygenase-2(COX-2),prostaglandin E2 and platelet-derived growth factor(PDGF)were measured by enzyme-linked immunosorbent assay,and the levels of VEGF,p53 and Ki-67 were measured by immunohistochemistry.RESULTS:In malignant tissue,compared with normal tissue,the levels of totalω-6 PUFAs(24.64%±3.41%vs 26.77%±3.37%,P=0.00)and linoleic acid(LA)(15.46%±3.51%vs 18.30%±2.83%,P0.01)were lower,whereas the levels of totalω-3 PUFAs(1.58%±0.74%vs 1.35%±0.60%,P0.01)and dihomo-gamma-linolenic acid(DGLA)(1.32%±0.69%vs 0.85%±0.29%,P0.01)were significantly higher.The ratios of arachidonic acid(AA)/LA(0.53±0.22 vs0.42±0.19,P0.01)and AA/totalω-6 PUFAs(0.31±0.09 vs 0.27±0.10,P0.01)were also significantly higher in malignant tissue.The levels of PDGF(353.10±148.85 pg/m L vs 286.09±104.91 pg/m L,P0.01),COX-2(125.21±70.29 ng/m L vs 67.06±42.22 ng/m L,P0.01)and VEGF(357.11±128.76 pg/m L vs211.38±99.47 pg/m L,P0.01)were also higher in malignant tissue compared to normal tissue.COX-2was inversely correlated with LA(R=-0.3244,P0.05)and positively correlated with AA/totalω-6 PUFAs(R=0.3083,P0.05)and AA/LA(R=0.3001,P0.05).The tissue level of LA was highest in poorly differentiated tumors(19.9%±6.3%,P0.05),while the ratio of AA/ω-3 PUFAs was lowest in these tumors(10.8±2.6,P0.05).In VEGF-positive tumors,the level of LA was higher(16.2%±3.7%vs 13.9%±2.7%,P0.01),while the AA/ω-3PUFA,AA/ω-6 PUFA,and AA/LA ratios were lower than in VEGF-negativetumors(5.0±1.8 vs 6.7±3.3,0.30±0.09 vs 0.34±0.09,0.50±0.21 vs 0.61±0.21,P0.01).CONCLUSION:The metabolism of PUFAs may playan important role in the evolution of inflammationdriven tumorigenesis in CRC and may be considered apotential marker for prognosis.     

Aberrant TGF-β1 signaling contributes to the development of primary biliary cirrhosis in murine model

AIM:To investigate whether transforming growth factor-β1(TGF-β1)signaling pathway is involved in the pathogenesis of primary biliary cirrhosis(PBC).METHODS:A murine model of PBC was developed by injection of polyinosinic polycytidylic acids(polyⅠ:C)in C57BL/6 mice,and the liver expressions of TGFβ1,TGF-βreceptorⅠ(TβRⅠ),TGF-βreceptorⅡ(TβRⅡ),p-Smad2/3,monoclonalα-smooth muscle actin antibody(α-SMA)andα1(Ⅰ)collagen in the mouse model and control mice were evaluated by immunohistochemistry,immunoblotting and real-time polymerase chain reaction(RT-PCR).Lymphocyte subsets in liver were analyzed using flow cytometry.RESULTS:The mouse model had several key phenotypic features of human PBC,including elevated levels of alkaline phosphatase,antimitochondrial antibodies,portal bile ducts inflammation,and progressive collagen deposition.Compared with control mice,protein and mRNA levels of TGFβ1,TβRⅠ,TβRⅡ,p-Smad2/3,α-SMA andα1(Ⅰ)collagen in liver(1.7±0.4 vs 8.9±1.8,0.8±0.2 vs 5.1±1.5,0.6±0.01 vs5.1±0.1,0.6±0.3 vs 2.0±0.3,0.9±0.4 vs 3.4±0.6,0.8±0.4 vs 1.7±0.3,1.1±1.2 vs 11.8±0.6,P<0.05),and the total number and percentage of CD4+CD25+FOXP3+and CD8+lymphocytes(0.01±0.001vs 0.004±0.00,0.12±0.04 vs 0.52±0.23,P<0.01)were higher in the mouse model.CONCLUSION:TGFβ1 might play a dual role in the development of PBC:it suppresses inflammatory response but operates to enhance fibrogenesis.The aberrant activity of TGF-β1 signaling contributes to the development of PBC.     

Health-related quality of life of 256 recipients after liver transplantation

AIM:To investigate health-related quality of life(HRQoL) and psychological outcomes in 256 adults who had undergone liver transplantation(LT).METHODS:A stratified random sampling method was used in this follow-up multicenter study to select a representative sample of recipients undergoing either living donor liver transplantation(LDLT) or deceased donor liver transplantation(DDLT).HRQoL was measured by using the Chinese version of Medical Outcome Study Short Form-36(SF-36),and psychological outcomes by using the beck anxiety inventory(BAI) and the self-rating depression scale(SDS).Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaires.RESULTS:A total of 256 patients were sampled,including 66(25.8%) receiving LDLT and 190(74.2%) undergoing DDLT;15(5.9%) recipients had anxiety and four(1.6%) developed severe depression after the operation.Compared with LDLT recipients,DDLT patients had higher scores in general health(60.33 ± 16.97 vs 66.86 ± 18.42,P = 0.012),role-physical(63.64 ± 42.55 vs 74.47 ± 36.46,P = 0.048),roleemotional(61.11 ± 44.37 vs 78.95 ± 34.31,P = 0.001),social functioning(78.60 ± 22.76 vs 88.16 ± 21.85,P = 0.003),vitality(70.30 ± 15.76 vs 75.95 ± 16.40,P = 0.016),mental health(65.88 ± 12.94 vs 71.85 ± 15.45,P = 0.005),physical component summary scale(PCS,60.07 ± 7.36 vs 62.58 ± 6.88,P = 0.013) and mental component summary scale(MCS,52.65 ± 7.66 vs 55.95 ± 10.14,P = 0.016).Recipients 45 years old at the time of transplant scored higher in vitality(77.33 ± 15.64 vs 72.52 ± 16.66,P = 0.020),mental health(73.64 ± 15.06 vs 68.00 ± 14.65,P = 0.003) and MCS(56.61 ± 10.00 vs 54.05 ± 9.30,P = 0.037) than those aged ≤ 45 years.MCS was poorer in recipients with than in those without complications(52.92 ± 12.21 vs 56.06 ± 8.16,P = 0.017).Regarding MCS(55.10 ± 9.66 vs 50.0 ± 10.0,P 0.05) and PCS(61.93 ± 7.08 vs 50.0 ± 10.0,P 0.05),recipients scored better than the Sichuan general and had improved overall QoL compared to patients with chronic diseases.MCS and PCS significantly correlated with scores of the BAI(P 0.001) and the SDS(P 0.001).CONCLUSION:Age 45 years at time of transplant,DDLT,full-time working,no complications,anxiety and depression were possible factors influencing postoperative HRQoL in liver recipients.