Could saline irrigation clear all residual common bile duct stones after lithotripsy?A self-controlled prospective cohort study

BACKGROUND A previous study showed that irrigation with 100 mL saline reduced residual common bile duct(CBD)stones,which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIM To determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODS This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large(>1.2 cm)CBD stones.After occlusion cholangiography confirmed CBD stone clearance,peroral cholangioscopy(POC)was performed to determine clearance scores based on the number of residual stones.The amounts of residual stones spotted via POC were graded on a 5-point scale(score 1,worst;score 5,best).Scores were documented after only stone removal(control)and after irrigation with 50 mL and 100 mL saline,respectively.The stone composition was analyzed using infrared spectroscopy.RESULTS Between October 2018 and January 2020,47 patients had CBD clearance scores of 2.4±1.1 without saline irrigation,3.5±0.7 with 50 mL irrigation,and 4.6±0.6 with 100 mL irrigation(P<0.001).Multivariate analysis showed that CBD diameter>15 mm[odds ratio(OR)=0.08,95%confidence interval(CI):0.01-0.49;P=0.007]and periampullary diverticula(PAD)(OR=6.51,95%CI:1.08-39.21;P=0.041)were independent risk factors for residual stones.Bilirubin pigment stones constituted the main residual stones found in patients with PAD(P=0.004).CONCLUSION Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy,especially in patients with PAD and/or a dilated(>15 mm)CBD.Pigment residual stones are soft and commonly found in patients with PAD.Additional saline irrigation may be required to remove retained stones.

Cytokines predict virological response in chronic hepatitis B patients receiving peginterferon alfa-2a therapy

BACKGROUND Chronic hepatitis B virus infection remains a major global public health problem.Peginterferon-alpha-2a(PEG-IFN)has direct antiviral and immunoregulatory effects,and it has become one of the first choice drugs for the treatment of chronic hepatitis B(CHB).Cytokines play an important role in immunity,and they directly inhibit viral replication and indirectly determine the predominant pattern of the host immune response.AIM To determine the correlation between cytokine/chemokine expression levels and response to PEG-IFN treatment in patients with CHB.METHODS Forty-six kinds of cytokines were analyzed before PEG-IFN therapy and at 24 wk during therapy in 26 CHB patients.RESULTS The monokine induced by INF-γ(CXCL9)and serum interferon-inducible protein 10(IP-10)levels at baseline were higher in virological responders than in nonvirological responders(NRs)and decreased during treatment,whereas the NRs did not exhibit significant changes.The macrophage inflammatory protein 1d(MIP-1d)levels at baseline and during treatment were significantly higher in the virological responders than in the NRs,while thymus and activation-regulated chemokine(TARC)levels at baseline and during treatment were significantly lower in the virological responders than in the NRs.The CXCL9,IP-10,MIP-1d,and TARC baseline levels exhibited the expected effects for interferon treatment.The area under the receiver operating characteristic curve values of CXCL9,IP-10,MIP-1d,and TARC for predicting virological responses were 0.787,0.799,0.787,and 0.77(P=0.01,0.013,0.01,and 0.021),respectively.CONCLUSION We found that cytokine levels before and during treatment may represent potential biomarkers to select CHB patients who can respond to PEG-IFN.Therefore,cytokines can be used as an indicator of antiviral drug selection before CHB treatment.

Associations between serum uric acid and hepatobiliary-pancreatic cancer:A cohort study

BACKGROUND Uric acid is the end product of purine metabolism.Previous studies have found that serum uric acid(SUA)levels are associated with the total cancer risk.However,due to the dual effect of uric acid on cancer,the relationship between the SUA levels and most specific-site cancer remains unclear.AIM To investigate the associations between the SUA levels and incidence of hepatobiliary-pancreatic cancer.METHODS In this prospective cohort study,444462 participants free of cancer from the UK Biobank were included.The SUA levels were measured at baseline,and the incidence of hepatobiliary-pancreatic cancer was determined by contacting the cancer registry.The hazard ratios(HRs)and 95%confidence intervals(CIs)between the SUA levels and hepatobiliary-pancreatic cancer were investigated using multiple adjusted Cox regression models adjusted for potential confounders.RESULTS In total,920 participants developed liver,gallbladder,biliary tract or pancreatic cancer during a median of 6.6 yrs of follow-up.We found that the HR of pancreatic cancer in the highest SUA group was 1.77(95%CI:1.29-2.42)compared with that in the lowest group.After stratifying by gender,we further found that SUA was associated with an increased risk of pancreatic cancer only among the females(highest quartile vs lowest quartile HR 2.04,95%CI:1.35-3.08).Among the males,the SUA levels were positively associated with the gallbladder cancer risk(highest quartile vs lowest quartile HR 3.09,95%CI:1.28-7.46),but a U-shaped association with the liver cancer risk was observed(P-nonlinear=0.03).CONCLUSION SUA is likely to have gender-specific effects on hepatobiliary-pancreatic cancer.High SUA levels are a risk factor for pancreatic cancer in females and gallbladder cancer in males.A U-shaped association with the liver cancer risk was identified.

A novel endoscopic retrograde cholangiopancreatography technique to reduce stone size in type IV Mirizzi syndrome: avoiding cholangiojejunostomy

To the Editor:Mirizzi syndrome(MS)is a rare type of cholelithiasis with an incidence of 0.1%in all gallstone.[1]cases.Its clinical manifestations and imaging features can sometimes be diffcult to distinguish from those of choledocholithiasis and biliary tumors.s.The traditional treatment for MS is usually surgery,including cholecys-tectomy,exploration of common bile.duct plus T-tube drainage,and cholangiojejunostomy.[2] There have even been reports of endoscopic therapies for MS in recent years,but it is technically difficult and non-feasible in cases where the stones get stuck in the Hartmann pouch.[3]Here we report a case where the MS was downstaged via endoscopic modalities to avoid cholangiojejunostomy.