Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis(AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.

Contrast-enhanced harmonic endoscopic ultrasonography for assessment of lymph node metastases in pancreatobiliary carcinoma

AIM: To assess the usefulness of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for lymph node metastasis in pancreatobiliary carcinoma.METHODS: All patients suspected of pancreatobiliary carcinoma with visible lymph nodes after standard EUS between June, 2009 and January, 2012 were enrolled. In the primary analysis, patients with successful EUS-fine needle aspiration (FNA) were included. The lymph nodes were assessed by several standard EUS variables (short and long axis lengths, shape, edge characteristic and echogenicity), color Doppler EUS variable [central intranodal blood vessel (CIV) presence] and CH-EUS variable (heterogeneous/homogeneous enhancement patterns). The diagnostic accuracy relative to EUS-FNA was calculated. In the second analysis, N-stage diagnostic accuracy of CH-EUS was compared with EUS-FNA in patients who underwent surgical resection.RESULTS: One hundred and nine patients (143 lymph nodes) fulfilled the criteria. The short axis cut-off ≥ 13 mm predicted malignancy with a sensitivity and specificity of 72% and 85%, respectively. These values were 72% and 63% for the long axis cut-off ≥ 20 mm, 62% and 75% for the round shape variable, 81% and 30% for the sharp edge variable, 66% and 61% for the hypoechogenicity variable, 70% and 72% for the CIV-absent variable, and 83% and 91% for the heterogeneous CH-EUS-enhancement variable, respectively. CH-EUS was more accurate than standard and color Doppler EUS, except the short axis cut-off. Notably, three patients excluded because of EUS-FNA failure were correctly N-staged by CH-EUS.CONCLUSION: CH-EUS complements standard and color Doppler EUS and EUS-FNA for assessment of lymph node metastases.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis: Long-term outcomes after removal of a self-expandable metal stent

AIM To assess the long-term outcomes of this procedure after removal of self-expandable metal stent(SEMS). The efficacy and safety of endoscopic ultrasoundguided gallbladder drainage(EUS-GBD) with SEMS were also assessed.METHODS Between January 2010 and April 2015, 12 patients with acute calculous cholecystitis, who were deemed unsuitable for cholecystectomy, underwent EUSGBD with a SEMS. EUS-GBD was performed under the guidance of EUS and fluoroscopy, by puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS. TheSEMS was removed and/or replaced with a 7-Fr plastic pigtail stent after cholecystitis improved. The technical and clinical success rates, adverse event rate, and recurrence rate were all measured.RESULTS The rates of technical success, clinical success, and adverse events were 100%, 100%, and 0%, respectively. After cholecystitis improved, the SEMS was removed without replacement in eight patients, whereas it was replaced with a 7-Fr pigtail stent in four patients. Recurrence was seen in one patient(8.3%) who did not receive a replacement pigtail stent. The median follow-up period after EUS-GBD was 304 d(78-1492).CONCLUSION EUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis. Long-term outcomes after removal of the SEMS were excellent. Removal of the SEMS at 4-wk after SEMS placement and improvement of symptoms might avoid migration of the stent and recurrence of cholecystitis due to food impaction.

Modified single transluminal gateway transcystic multiple drainage technique for a huge infected walled-off pancreatic necrosis: A case report

We report a successful endoscopic ultrasonographyguided drainage of a huge infected multilocular walledoff necrosis(WON) that was treated by a modified single transluminal gateway transcystic multiple drainage(SGTMD) technique. After placing a widecaliber fully covered metal stent, follow-up computed tomography revealed an undrained subcavity of WON. A large fistula that was created by the wide-caliber metal stent enabled the insertion of a forward-viewing upper endoscope directly into the main cavity, and the narrow connection route within the main cavity to the subcavity was identified with a direct view, leading to the successful drainage of the subcavity. This modified SGTMD technique appears to be useful for seeking connection routes between subcavities of WON in some cases.

Evaluation of anti-migration properties of biliary covered self-expandable metal stents

AIM: To assess anti-migration potential of six biliary covered self-expandable metal stents(C-SEMSs) by using a newly designed phantom model. METHODS: In the phantom model, the stent was placed in differently sized holes in a silicone wall and retracted with a retraction robot. Resistance force to migration(RFM) was measured by a force gauge on the stent end. Radial force(RF) was measured with a RF measurement machine. Measured flare structure variables were the outer diameter, height, and taper angle of the flare(ODF, HF, and TAF, respectively). Correlations between RFM and RF or flare variables were analyzed using a linear correlated model.RESULTS: Out of the six stents, five stents were braided, the other was laser-cut. The RF and RFM of each stent were expressed as the average of five replicate measurements. For all six stents, RFM and RF decreased as the hole diameter increased. For all six stents, RFM and RF correlated strongly when the stent had not fully expanded. This correlation was not observed in the five braided stents excluding the laser cut stent. For all six stents, there was a strong correlation between RFM and TAF when the stent fully expanded. For the five braided stents, RFM after full stent expansion correlated strongly with all three stent flare structure variables(ODF, HF, and TAF). The laser-cut C-SEMS had higher RFMs than the braided C-SEMSs regardless of expansion state.CONCLUSION: RF was an important anti-migration property when the C-SEMS did not fully expand. Once fully expanded, stent flare structure variables plays an important role in anti-migration.

Ergogenic Capacity of a 7-Chinese Traditional Medicine Extract in Aged Mice

The ergogenic properties of a 7-Chinese traditional medicine water extract (Ligustrum lucidum ait, LLA), which is composed of the essences of Lycii fructus, Crataegi fructus, Phyllanthi fructus, Chrysanthemi flos, Coicis semen, Ganoderma lucidum, and Zizyphi fructus, were studied using aged mice. Mice were chronically (one month) administered LLA (0.1% and 1%) in the drinking water. Mice pre-treated with LLA showed a good appetite;however, they exhibited a lower rate of body weight increase compared to control mice. In mice subjected to the rotarod test, 1% LLA treatment provided effective adaption to fatigue and significantly increased the duration of mice on the rotarod. In locomotor activity test, 1% LLA potentiated mice mobility and significantly increased rearing behavior. In the antioxidant experiment, 1% LLA treatment significantly increased superoxide dismutase activity in the spleen and liver glutathione levels. These findings suggest that LLA may be utilized as an antifatigue agent, which may function through its antioxidant activity.

Potential antioxidant bioactive peptides from camel milk proteins

Camel milk is traditionally considered to have medicinal characteristics that it has potential health benefits and could help to treat several illnesses. Particularly, it is closest to human breast milk and has high levels of nutrients and bioactive components. The aim of this study was to explore the antioxidant peptides derived from protein fractions of camel milk. Camel milk proteins(CMP) were fractionated into camel casein protein(CCP) and camel whey protein(CWP), which were hydrolyzed with pepsin to produce peptic digests P-CCP and P-CWP, respectively. RP-HPLC was used for fractionation of the peptides from the P-CCP and P-CWP. The antioxidant activities were evaluated using superoxide anion generating system of xanthine oxidase(XOD)and 2,2-diphenyl-1-picrylhydrazyl(DPPH) scavenging assay. Active peptides were analyzed using matrixassisted laser desorption ionization time of flight mass spectrometry(MALDI-TOF-MS) whereas a number of antioxidant peptides, with masses ranging from 913 to 2,951 Da, derived mainly from alpha-casein, lactophorin and lactoferrin, were identified. When yeast cells are used as a system for modeling mitochondrial disease, the peptides in caseins and whey fractions significantly enhanced the tolerance of yeast cells against peroxide-induced oxidative stress. The results show that both caseins and whey proteins of camel milk possess bioactive peptides with significant radical-scavenging activities and thus herald a fascinating opportunity for their potential as nutraceuticals or therapeutic peptides for prevention and treatment of oxidative stress-associated diseases.

Potent antioxidant peptides derived from honey major protein enhance tolerance of eukaryotic cells toward oxidative stress

Honey is known for its medicinal benefits and receiving renewed attention as natural medicine.Studies on health benefits of honey attributed its antioxidant activity to phenolic compounds,but the contribution of proteins and peptides to the antioxidant activity of honey is lacking.The aim of this study was to explore the contribution of proteins and peptides to the antioxidant activity of honey,which remained obscure for decades.Total honey proteins(THP)were isolated by dialysis method and hydrolyzed through simulated gastrointestinal digestion.The hydrolysates were fractionated using size-exclusion chromatography.The antioxidant activity was determined by using superoxide radical-scavenging,DPPH reduction and intracellular ROS assays.THP was shown to exhibit superoxide-scavenging activity but its pepsin-hydrolysate(HP-p)showed superior scavenging activity.The HP-p produced five peptide fractions(P1~P5)when fractionated on Sephacryl S-100 size-exclusion column.The five fractions showed superoxide-scavenging activities and DPPH reducing activities,whereas the slow-eluting peptide fractions(P3 and P4)were the most potent.MALDI-TOF/MS analysis identified a pentapeptide(TSNTF)as the dominant peptide in the active fractions P3 and P4.Human colonic epithelial cells treated with P3 and P4 peptides exhibited lower intracellular ROS,when oxidative stress was induced by H2O2 or diethyl maleate(DEM),indicating strong tolerance to oxidative stress.The viabilities of human cells or yeast cells were largely decreases under oxidative stress,but treated cells with P3 and P4 showed higher viability compared with the untreated cells.The results are the first to describe a novel antioxidant peptide from honey that confer ex vivo anti-oxidative function within a complicated milieu of eukaryotic cells and pave the way for its potential as nutraceutical or therapeutic peptide for risk-reduction of oxidative-stress and related diseases.