Promising biological therapies for ulcerative colitis: A review of the literature

Ulcerative colitis(UC) is a chronic lifelong condition characterized by alternating flare-ups and remission. There is no single known unifying cause, and the pathogenesis is multifactorial, with genetics, environmental factors, microbiota, and the immune system all playing roles. Current treatment modalities for UC include 5-aminosalicylates, corticosteroids, immunosuppressants(including purine antimetabolites, cyclosporine, and tacrolimus), and surgery. Therapeutic goals for UC are evolving. Medical treatment aims to induce remission and prevent relapse of disease activity. Infliximab, an anti-tumor necrosis factor(TNF)-α monoclonal antibody, is the first biological agent for the treatment of UC. Over the last decade, infliximab and adalimumab(anti-TNF-α agents) have been used for moderate to severe UC, and have been shown to be effective in inducing and maintaining remission. Recent studies have indicated that golimumab(another anti-TNF-α agent), tofacitinib(a Janus kinase inhibitor), and vedolizumab and etrolizumab(integrin antagonists), achieved good clinical remission and response rates in UC. Recently, golimumab and vedolizumab have been approved for UC by the United States Food and Drug Administration. Vedolizumab may be used as a first-line alternative to anti-TNF-α therapy in patients with an inadequate response to corticosteroids and/or immunosuppressants. Here, we provide updated information on various biological agents in the treatment of UC.

Immediate detection of endoscopic retrograde cholangiopancreatographyrelated periampullary perforation: Fluoroscopy or endoscopy?

AIM:To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography(ERCP)-related perforations to support immediate or early diagnosis.METHODS:Consecutive patients who underwent ERCP procedures at our hospital between January2008 and June 2013 were retrospectively enrolled in the study(n=2674).All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation.For patients showing alterations in the gastrointestinal anatomy,a short-type double balloon enteroscope had been applied.Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitonealspace,or upon endoscopic detection of an abdominal cavity related to the perforated lumen.For patients with ERCP-related perforations,the data on medical history,endoscopic findings,radiologic findings,diagnostic methods,management,and clinical outcomes were used for descriptive analysis.RESULTS:Of the 2674 ERCP procedures performed during the 71-mo study period,only six(0.22%)resulted in perforations(male/female,2/4;median age:84 years;age range:57-97 years).The cases included an endoscope-related duodenal perforation,two periampullary perforations related to endoscopic sphincterotomy,two periampullary perforations related to endoscopic papillary balloon dilation,and a periampullary or bile duct perforation secondary to endoscopic instrument trauma.No cases of guidewire-related perforation occurred.The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation;the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively(at a median post-ERCP intervention time of 15 min).Three out of the six total perforation cases,including the single case of endoscope-related duodenal injury,were surgically treated;the remaining three cases were treated with conservative management,including trans-arterial embolization to control the bleeding in one of the cases.All patients recovered without further incident.CONCLUSION:ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.

Clinical outcomes of Clutch Cutter endoscopic submucosal dissection for older patients with early gastric cancer

AIM To evaluate the clinical outcome of endoscopic submucosal dissection using the Clutch Cutter(ESDCC) in older patients. METHODS We reviewed 232 consecutive patients with early gastric cancer who underwent ESDCC between June 2010 and February 2014 at Aso Iizuka Hospital. We divided patients into two groups according to age: Older patients(> 80 years, n = 64) and non-older patients(≤ 80 years, n = 168). We retrospectively compared the prevalence rates of pre-existing comorbidities, anticoagulant therapy, en bloc resection, mean duration of hospitalization, incidence of ESDCC-related complications, change in performance status(PS) before and after ESDCC, and financial cost of admission. RESULTS The older group comprised 64 patients with a mean age of 84.1 years, and the non-older group comprised 168 patients with a mean age of 69.5 years. Older patients had significantly more pre-existing comorbidities than did non-older patients, specifically heart disease(P < 0.05). The en bloc resection rate in non-older patients was significantly higher than that in older patients(100% vs 95.3%, P = 0.02). There were no significant differences between the older and non-older groups in the incidence of ESDCC-related complications(i.e., postoperative bleeding and perforation) and the post-ESDCC change in PS. There were also no significant differences between the older and non-older groups in the mean duration of hospitalization(11.4 and 10.7 d, respectively) and financial cost of admission(657040 JPY and 574890 JPY, respectively).CONCLUSION ESDCC has a good clinical outcome in older patients.