Diagnostic criteria for autoimmune chronic pancreatitis revisited

自体免疫的慢性胰炎(AIP ) 逐渐地正在是广泛地认出了世界，，这个实体的知识积聚。首先， AIP 以它对与平常的慢性胰炎相对照的口头的类固醇治疗的戏剧的反应是到临床医生的很吸引人的疾病。尽管 AIP 的许多典型调查结果被描述了，明确的诊断标准充分没被建立。在一年 2002，日本胰社会在全世界出版了 AIP 和许多临床医生的诊断标准为 AIP 的诊断使用这些标准。然而，日本胰社会建议的诊断标准不是完全令人满意的，一些组在报导 AIP 使用他们的自己的标准。这评论为这个逐渐地公认的条件讨论当前的诊断标准的几潜在的限制。手稿被组织强调对召开一致发展的需要改进了诊断标准。

Prevalence of clonorchiasis in patients with gastrointestinal disease: A Korean nationwide multicenter survey

AIM: To investigate prevalence of Clonorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea.METHODS: Consecutive patients who had been admitted to the Division of Gastroenterology with gastrointestinal symptoms were enrolled from March to April 2005. Of those who had been diagnosed with clonorchiasis, epidemiology and correlation between infection and hepatobiliary diseases were surveyed by questionnaire.RESULTS: Of 3080 patients with gastrointestinal diseases, 396 (12.9%) had clonorchiasis and 1140 patients (37.2%) had a history of eating raw freshwater fish. Of those with a history of raw freshwater fish ingestion, 238 (20.9%) patients had clonorchiasis. Cholangiocarcinoma was more prevalent in C. sinensis-infected patients than non-infected patients [34/396 (8.6%) vs 145/2684 (5.4%), P = 0.015]. Cholangiocarcinoma and clonorchiasis showed statistically significant positive cross-relation (P = 0.008). Choledocholithiasis, cholecystolithiasis, cholangitis, hepatocellular carcinoma, and biliary pancreatitis did not correlate with clonorchiasis.CONCLUSION: Infection rate of clonorchiasis was still high in patients with gastrointestinal diseases in Korea, and has not decreased very much during the last two decades. Cholangiocarcinoma was related to clonorchiasis, which suggested an etiological role for the parasite.

Endoscopic papillary balloon dilation:Revival of the old technique

Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy(EST)in young patients undergoing laparoscopic cholecystectomy.However,there is a disparity in using endoscopic balloon papillary dilation(EPBD)between the East and the West,depending on the origin of the studies.In the early 2000s,EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones.Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method,unlike EPBD.However,fatal complications have occurred in patients with endoscopic papillary large balloon dilation(EPLBD).The safety of endoscopic balloon dilation is still a debatable issue.Moreover,guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon.In this article,we discuss the issue of conventional and large balloon endoscopic dilation.We also suggest the indications and optimal techniques of EPBD and EPLBD.

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis:From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography(ERCP)is post-ERCP pancreatitis (PEP),which occurs in up to 40%of patients.Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk.A decade ago,Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP,which can be divided into patient-relat-ed and procedure-related issues.In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view.This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.

Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents

AIM:To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) with a fully covered self-expandable metallic stent(FCSEMS).METHODS:From April 2009 to August 2010,15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography(ERCP) were included.These 15 patients consisted of 8 men and 7 women and had a median age of 61 years(range:30-91 years).The underlying causes of the distal malignant biliary obstruction were pancreatic cancer(n = 9),ampulla of Vater cancer(n = 2),renal cell carcinoma(n = 1),advanced gastric cancer(n = 1),lymphoma(n = 1),and duodenal cancer(n = 1).RESULTS:The technical success rate of EUS-CDS with an FCSEMS was 86.7%(13/15),and functional success was achieved in 100%(13/13) of those cases.In two patients,the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct.The mean duration of stent patency was 264 d.Early adverse events developed in three patients(3/13,23.1%),including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient.During the follow-up period(median:186 d,range:52-388 d),distal stent migration occurred in four patients(4/13,30.8%).In 3 patients,the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.CONCLUSION:EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy

AIM:To evaluate the success rates,procedural time and adverse event rates of the modified methods in endoscopic ultrasonography-guided hepaticogastrostomy(EUS-HGS).METHODS:Twenty-eight patients in a prospective case series who underwent EUS-HGS(phaseⅠ).Fortysix patients in a matched case-control study(phaseⅡ).The simplified technique for fistula dilation was the primary use of a 4 mm balloon catheter with a stainless steel stylet.The stent deployment was modified by deploying the metal stent inside a bile duct(half of the stent)under EUS and fluoroscopic guidance and gently pulling the echoendoscope after full deployment of the stent inside the echoendoscope channel(remaining portion of the stent)under fluoroscopic guidance.This cohort was compared with a matched historical cohort.RESULTS:In phaseⅠ,the technical and clinical success with the modified method was 96%(27/28)and89%(24/27 as per-protocol analysis).The overall adverse event rate was 7%.In phaseⅡ,there was no difference in technical and clinical success,stent patency and overall adverse events in each group.However,the procedural time(15.3±5.2 min vs 22.3±6.0 min,P<0.001)and early adverse events(0%vs 26%,P=0.02)were statistically improved in case cohort compared with control cohort.CONCLUSION:Compared with the conventional EUSHGS technique,the procedural time was shorter and early adverse events were less frequent with our simplified and modified technique.

Early bile duct cancer

Bile duct cancers are frequently diagnosed as advanced diseases. Over half of patients with advanced bile duct cancer present with unresectable malignancies and their prognosis has been very poor even after curative resections. Although there has been a need to diagnose bile duct cancer at its early stage, it has been a diffi cult goal to achieve due to our lack of knowledge regarding this disease entity. Early bile duct cancer may be defi ned as a carcinoma whose invasion is confined within the fibromuscular layer of the extrahepatic bile duct or intrahepatic large bile duct without distant metastasis irrespective of lymph node involvement. Approximately 3%-10% of resected bile duct cancers have been reported to be early cancers in the literature. The clinicopathological features of patients with early bile duct cancer differ from those of patients with advanced bile duct cancer, with more frequent asymptomatic presentation, characteristic histopathological findings, and excellent prognosis. This manuscript is organized to emphasize the need for convening an international consensus to develop the concept of early bile duct cancer.

Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

Background:Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy(ASGE)and reported only suboptimal accuracy.This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography(CT)and role of endoscopic ultrasonography(EUS)and magnetic resonance cholangiopancreatography(MRCP)in patients with suspected choledocholithiasis but negative CT finding.Methods:Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed.All patients underwent CT to detect choledocholithiasis.EUS or MRCP was performed when the CT scan showed negative findings.Patients were classified into the high and intermediate-risk groups,based on predictors from the ASGE criteria.Results:Of 583 patients with suspected choledocholithiasis,340(58.3%)had stones on ERCP(65.9%in the high-risk group and 40.6%in the intermediate-risk group).The accuracy of ASGE guideline for CT was 63.98%(79.12%sensitivity,42.80%specificity)and 36.02%(20.88%sensitivity,57.20%specificity)in the high-risk and intermediate-risk groups,respectively.In 103 patients in the high-risk group underwent both CT and US,the accuracy of CT was higher than that of US for detecting choledocholithiasis(78.64%vs.53.40%),with a significant difference in area under the curve(AUC)(0.78 vs.0.59,P<0.001).Of 339 with negative CT finding,the accuracy of EUS was higher than that of MRCP(90.91%vs.82.76%),but with no significant difference in AUC(0.91 vs.0.83,P=0.347).Conclusions:CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis.The diagnostic options,EUS or MRCP,with negative CT finding showed comparable performance.Therefore,the diagnostic modality should be selected based on availability,experience,cost,and contraindications.

Clinical course of ulcerative colitis patients who develop acute pancreatitis

AIM To investigate the clinical course of ulcerative colitis(UC)patients who develop acute pancreatitis.METHODS We analyzed 3307 UC patients from the inflammatory bowel disease registry at Asan Medical Center from June 1989 to May 2015.The clinical course of UC patients who developed acute pancreatitis was compared with that of non-pancreatitis UC patients.RESULTS Among 51 patients who developed acute pancreatitis,13(0.40%)had autoimmune,10(0.30%)had aminosalicylate-induced,and 13(1.73%)had thiopurineinduced pancreatitis.All 13 patients with autoimmune pancreatitis(AIP)had type 2 AIP.Two(15.4%)patients had pre-existing AIP,and three(23.1%)patients developed AIP and UC simultaneously.Compared to non-pancreatitis patients,AIP patients had UC diagnosed at a significantly younger age(median,22.9 years vs 36.4 years;P=0.001).AIP and aminosalicylate-induced pancreatitis patients had more extensive UC compared to non-pancreatitis patients.All patients with pancreatitis recovered uneventfully,and there were no recurrences.Biologics were used more frequently in aminosalicylate-and thiopurine-induced pancreatitis patients compared to non-pancreatitis patients[adjusted OR(95%CI),5.16(1.42-18.67)and6.90(1.83-25.98),respectively].Biologic utilization rate was similar among AIP and non-pancreatitis patients[OR(95%CI),0.84(0.11-6.66)].Colectomy rates for autoimmune,aminosalicylate-induced,and thiopurineinduced pancreatitis,and for non-pancreatitis patients were 15.4%(2/13),20%(2/10),15.4%(2/13),and7.3%(239/3256),respectively;the rates were not significantly different after adjusting for baseline disease extent.CONCLUSION Pancreatitis patients show a non-significant increase in colectomy,after adjusting for baseline disease extent.

A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model

AIM:To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for onestep endoscopic ultrasound(EUS)-guided biliary drainage(EUS-BD)in a new experimental biliary dilatation porcine model.METHODS:A novel dedicated device for one-step EUS-guided biliary drainage system(DEUS)introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation.A self-expandable metal stent,consisting of both uncovered and nitinol-covered portions,was preloaded into DEUS introducer.After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs,EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices.RESULTS:One-step EUS-BD was technically successful in seven pigs[7/9(77.8%)as intention to treat]without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic(n=2)or common hepatic(n=5)duct.Primary technical failure occurred in two cases that did not show adequate biliary dilatation.In seven pigs with a successful bile duct dilatation,the technical success rate was 100%(7/7 as per protocol).Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min(IQR;8.9-18.1).There were no immediate procedure-related complications.CONCLUSION:Modified tapered metal tip and low profile introducer may be technically feasible for onestep EUS-BD in experimental porcine model.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to sixstitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Forward-viewing endoscopic ultrasound-guided NOTES interventions: A study on peritoneoscopic potential

AIM:To evaluate the feasibility of diagnostic and therapeutic transgastric(TG)peritoneoscopic interventions with a forward-viewing endoscopic ultrasound(FV-EUS).METHODS:This prospective endoscopic experimental study used an animal model.Combined TG peritoneoscopic interventions and EUS examination of the intraabdominal organs were performed using an FV-EUS on 10 animal models(1 porcine and 9 canine).The procedures carried out include EUS evaluation and endoscopic biopsy of intraperitoneal organs,EUS-guided fine needle aspiration(EUS-FNA),EUS-guided radiofrequency ablation(EUS-RFA),and argon plasma coagulation(APC)for hemostatic control.The animals were kept alive for 7 d,and then necropsy was performed to evaluate results and complications.RESULTS:In all 10 animals,TG peritoneoscopy,followed by endoscopic biopsy for the liver,spleen,abdominal wall,and omentum,was performed successfully.APC helped control minor bleeding.Visualization of intra-abdominal solid organs with real-time EUS was accomplished with ease.Intraperitoneal EUS-FNA was successfully performed on the liver,spleen,and kidney.Similarly,a successful outcome was achieved with EUSRFA of the hepatic parenchyma.No adverse events were recorded during the study.CONCLUSION:Peritoneoscopic natural orifice transluminal endoscopic surgery(NOTES)interventions through FV-EUS were feasible in providing evaluation and performing endoscopic procedures.It promises potential as a platform for future EUS-based NOTES.

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However,up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula,which remains a serious problem and usually requires prolonged hospitalization,or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage,which were endoscopically closed with fibrin glue injection via the necrotic cavity.

未行手术及放化疗的进展性胆管癌自然史和预后因素的大型观察性研究

背景胆管癌是仅次于肝细胞肝癌的第二位最常见的肝胆肿瘤。其发病率仍在稳步上升,而许多患者在诊断时已是晚期失去手术机会。本文主要是研究未行治疗胆管癌患者从其诊断到死亡的自然史,从而评估其生存期和预后因素。复习文献,这是第一篇关于未行干预治疗的胆管癌生存期的大宗病例研究,希望他们的结果能够为胆管癌治疗疗效评估提供参考。

用于电流馈电双有源桥式变换器的控制漏感高频变压器的设计优化

用于光伏发电的电流馈电双有源电桥转换器通常可能需要给定的泄漏或额外的电感，以便提供对电流的适当控制。因此，许多研究都集中在高频变压器的漏感控制上，以集成一个额外的电感器。本文提出了一种非对称绕组配置，以获得高频变压器的受控漏电感，以提高电流馈电双有源桥式变换器的效率。为了精确分析，该设计使用了与高频开关电路相连的变压器的耦合电磁分析模型。通过利用设计分析模型，给出了高效率的设计优化步骤，并通过实验结果验证。