独到、苛评和在场的三位一体——论洪治纲的文学批评

从事文学批评是一项极其艰苦的事业,既要有充足的理论储备,又要有独到的见解和深刻的思想。洪治纲正是凭借扎实的理论基础和独到的见解使他的评论独树一帜。面对问题的一针见血和直言不讳又使他的评论成为当下的另类和标杆,独到源于自信,苛评来自赤诚。“在场”是他的主动追求,也是他的评论在当代文学的重要价值体现。

Prophylactic stenting for esophageal stricture prevention after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) of superficial esophageal cancer has been increasingly used as an alternative to surgery because it is minimally invasiveand has a high rate of en bloc resection. However, a high rate of esophageal stricture is observed after ESD for large lesions, which can dramatically decrease the patient's quality of life. Stricture prevention is necessary to allow for endoscopic therapy to expand. We, herein, review the most recent evidence and discuss the role of the metallic self-expandable stent and the biodegradable stent in esophageal stricture prevention. Limited studies suggested that prophylactic stenting could reduce the stricture rate without increasing the number of complications. In addition, the number of bougie dilation procedures was significantly lower with stent placement. Esophageal stenting is a promising option for post-ESD stricture prevention. However, current evidence is too preliminary to formulate practice standards. Future studies are needed to further validate the efficacy and safety of prophylactic stenting and determine the best strategy for stricture prevention. Stent migration is the most common complication. A new stent that has advantages of a low migration rate and minimal tissue reaction will need to be developed. Therefore, randomized controlled trials with long-term follow-up periods are required before prophylactic stenting could be considered a valid option to prevent post-ESD stricture.

Common controversies in management of biliary strictures

Biliary strictures are caused by a heterogeneous group of benign and malignant conditions, each requiring a specific treatment approach. Management of biliary strictures often involves endoscopy either for definite treatment, as a bridge to surgery or for palliative purposes. Endoscopic treatment of various types of biliary strictures is not standardized and there are multiple areas of controversy regarding the best treatment options. These controversies are mainly due to lack of well-designed comparative studies to support a specific therapy. This paper reviews three common areas of controversy in the endoscopic management of biliary strictures. The areas discussed in this editorial include the role of biliary drainage in resectable malignant strictures and whether such drainage should be performed routinely prior to surgery, the best endoscopic palliation for unresectable hilar strictures and whether unilateral or bilateral stenting should be attempted, and the optimal endoscopic management for dominant strictures in patients with primary sclerosing cholangitis. The goal of this editorial is twofold. The first is to review the current literature on management of the aforementioned strictures and offer recommendations based on available evidence. The second goal is to highlight the gaps in our knowledge which in turn can encourage future research on these topics.

Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review

AIM To evaluate the therapeutic role of double-balloon enteroscopy(DBE) in small bowel strictures and to propose a standard approach to small bowel strictures.METHODS Systematic review of studies involving DBE in patients with small bowel strictures. Only studies limited to small bowel strictures were included and those with ileo-colonic strictures were excluded. RESULTS In total 13 studies were included,in which 310 patients were dilated. The average follow-up time was 31.8 mo per patient. The complication rate was 4.8% per patient and 2.6% per dilatation. Surgery was avoided in 80% of patients. After the first dilatation,46% were treated with re-dilatation and only 17% required surgery.CONCLUSION DBE-assisted dilatation avoids surgery in 80% of patients with small bowel strictures and is safe and effective. We propose a standardized approach to small bowel strictures.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures(hepaticojejunostomy or choledechoduodenostomy).

Management of liver transplantation biliary stricture: Results from a tertiary hospital

AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation(OLT) during an 8-year period. METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys(ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used(multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical successrate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture(AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four(164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164(95.7%) patients with AS, that were treated with either multiple plastic(n = 109) or metallic billiary stents(n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents(c SEMS) and 4.1% in the multiple plastic stent(MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5%(c SEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the c SEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10(30.3%) patients in the c SEMS and 7(7.7%) in the plastic stent group, a statistically significant difference(P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the c SEMS and plastic stents groups. CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-toduct anastomosis. c SEMS was associated with increased pancreatitis risk and higher recurrence rate.

Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis

AIM To investigate endoscopic therapy efficacy for refractory benign biliary strictures(BBS) with multiple biliary stenting and clarify predictors.METHODS Ten consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents(7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct(CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.RESULTS Endoscopic therapy was completed in 8(80%) patients, whereas 2(20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two(20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six(60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group(6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation(complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.CONCLUSION Sequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.

Clinical impact of confocal laser endomicroscopy in the management of gastrointestinal lesions with an uncertain diagnosis

AIM To evaluate the clinical impact of confocal laser endomicroscopy(CLE) in the diagnosis and management of patients with an uncertain diagnosis.METHODS A retrospective chart review was performed.Patients who underwent CLE between November 2013 and October 2015 and exhibited a poor correlation between endoscopic and histological findings were included.Baseline characteristics,indications,previous diagnostic studies,findings at the time of CLE,clinical management and histological results were analyzed.Interventions based on CLE findings were also analyzed.We compared the diagnostic accuracy of CLE and target biopsies of surgical specimens.RESULTS A total of 144 patients were included.Of these,51%(74/144) were female.The mean age was 51 years old.In all,41/144(28.4%) lesions were neoplastic(13 bile duct,10 gastric,8 esophageal,6 colonic,1 duodenal,1 rectal,1 ampulloma and 1 pancreatic).The sensitivity,specificity,positive predictive value,negative predictive value,and observed agreement when CLE was used to detect N-lesions were 85.37%,87.38%,72.92%,93.75% and 86.81%,respectively.Cohen's Kappa was 69.20%,thus indicating good agreement.Changes in management were observed in 54% of the cases.CONCLUSION CLE is a new diagnostic tool that has a significant clinical impact on the diagnosis and treatment of patients with uncertain diagnosis.

Systematic review: Safety of balloon assisted enteroscopy in Crohn's disease

AIM To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy(BAE) in Crohn's disease(CD). METHODS Systematic review(PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy(DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease activity.RESULTS Per procedure perforation rate of diagnostic BAE in CD was 0.15%(95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications(0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12%(95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications(0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74%(95%CI: 0.85-3.55). Eighty-six percentof therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients. CONCLUSION Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.

Factors associated with complicated erosive esophagitis: A Japanese multicenter, prospective, cross-sectional study

AIM To assess the clinical characteristics of patients with complicated erosive esophagitis(EE) and their associated factors.METHODS This prospective, cross-sectional study included patients diagnosed with EE by upper gastrointestinal endoscopy between October 2014 and March 2015 at 106 Japanese hospitals. Data on medical history, general condition, gastrointestinal symptoms, lifestyle habits, comorbidities, and endoscopic findings were collected using a standard form to create a dedicated database. Logistic regression analysis was used to calculate adjusted odds ratios(aO R) and 95%CI for the association with complicated EE.RESULTS During the study period, 1749 patients diagnosed with EE, 38.3% of whom were prescribed proton pump inhibitors(PPIs) were included. Of them, 143(8.2%) had EE complications. Esophageal bleeding occurred in 84(4.8%) patients, esophageal strictures in 45(2.6%) patients, and 14(0.8%) patients experienced both. Multivariate analysis showed that increased age(a OR: 1.05; 95%CI: 1.03-1.08), concomitant use of psychotropic agents(a OR: 6.51; 95%CI: 3.01-13.61), and Los Angeles grades B(a OR: 2.69; 95%CI: 1.48-4.96), C(aO R: 15.38; 95%CI: 8.62-28.37), and D(aO R: 71.49; 95%CI: 37.47-142.01) were significantly associated with complications, whereas alcohol consumption 2-4 d/wk was negatively associated(a OR: 0.23; 95%CI: 0.06-0.61). Analyzing associated factors with each EE complication separately showed esophageal ulcer bleeding were associated with increased age(a OR: 1.05; 95%CI: 1.02-1.07) and Los Angeles grades B(aO R: 3.60; 95%CI: 1.52-8.50), C(a OR: 27.61; 95%CI: 12.34-61.80), and D(a OR: 119.09; 95%CI: 51.15-277.29), while esophageal strictures were associated with increased age(a OR: 1.07; 95%CI: 1.04-1.10), gastroesophageal reflux symptom(aO R: 2.51; 95%CI: 1.39-4.51), concomitantuse of psychotropic agents(a OR: 11.79; 95%CI: 5.06-27.48), Los Angeles grades C(aO R: 7.35; 95%CI: 3.32-16.25), and D(a OR: 20.34; 95%CI: 8.36-49.53) and long-segment Barrett's esophagus(a OR: 4.63; 95%CI: 1.64-13.05).CONCLUSION Aging and severe EE were common associated factors, although there were more associated factors in esophageal strictures than esophageal ulcer bleeding. Despite the availability and widespread use of PPIs, EE complications are likely to remain a problem in Japan owing to the aging population and high-stress society.

Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome

AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures(BDS) post living donor liver transplantation(LDLT).METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms(Pruritus, Jaundice, cholangitis), intra-op variables(cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis(HAT), bile leak, infections], stricture morphology(length, donor and recipient duct diameters) and relevant laboratory data both pre-and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.RESULTS Forty-one patients were included(age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients(48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy(multiple endoscopic retrogradecholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome(P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak(> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis(P < 0.05). CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.

Diagnosis and management of primary sclerosing cholangitis-perspectives from a therapeutic endoscopist

Primary sclerosing cholangitis(PSC) is a chronic,cholestatic liver condition characterized by inflammation,fibrosis,and destruction of the intra-and extrahepatic bile ducts.The therapeutic endoscopist plays a key role in the diagnosis and management of PSC.In patients presenting with a cholestatic profile,endoscopic retrograde cholangiopancreatography(ERCP) is warranted for a definite diagnosis of PSC.Dominant strictures of the bile duct occur in 36%-57% of PSC patients.Endoscopic balloon dilatation with or without stenting have been employed in the management of dominant strictures.In addition,PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk.Brush cytology obtained during ERCP and use of fluorescence in situ hybridization forms the initial diagnostic step in the investigation of patients with dominant biliary strictures.Our review aims to summarize the current evidence supporting the role of a therapeutic endoscopist in the management of PSC patients.

Improvedendoscopicretrogradecholangiopancreatographybrushincreases diagnosticyieldofmalignantbiliarystrictures

AIM: To determine if a new brush design could im-prove the diagnostic yield of biliary stricture brushings. METHODS: Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to proto-col implementation in July 2011, after which, a new 9 French wire-guided cytology brush(Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pa-thologists who determined whether the sample waspositive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen. RESULTS: Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular find-ings consistent with malignancy as compared to 17 of 46(37%) in the historical control group(P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes(21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to his-torical controls. CONCLUSION: The use of a new brush design for brush cytology of biliary strictures shows increased di-agnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clus-ters obtained.

Eosinophilic cholangitis is a potentially underdiagnosed etiology in indeterminate biliary stricture

AIM To investigate presence and extent of eosinophilic cholangitis(EC) as well as Ig G4-related disease in patients with indeterminate biliary stricture(IBS).METHODS All patients with diagnosis of sclerosing cholangitis(SC) and histopathological samples such as biopsies or surgical specimens at University Hospital Frankfurt from 2005-2015 were included. Histopathological diagnoses as well as further clinical course were reviewed. Tissue samples of patients without definite diagnosis after complete diagnostic work-up were reviewed regardingpresence of eosinophilic infiltration and Ig G4 positive plasma cells. Eosinophilic infiltration was as well assessed in a control group of liver transplant donors and patients with primary sclerosing cholangitis.RESULTS One hundred and thirty-five patients with SC were included. In 10/135 (13.5%) patients, no potential cause of IBS could be identified after complete diagnostic work-up and further clinical course. After histopathological review, a post-hoc diagnosis of EC was established in three patients resulting in a prevalence of 2.2% (3/135) of all patients with SC as well as 30%(3/10) of patients, where no cause of IBS was identified. 2/3 patients with post-hoc diagnosis of EC underwent surgical resection with suspicion for malignancy. Diagnosis of Ig G4-related cholangitis was observed in 7/135 patients (5.1%), whereas 3 cases were discovered in post-hoc analysis. 6/7 cases with Ig G4-related cholangitis (85.7%) presented with eosinophilic infiltration in addition to Ig G4 positive plasma cells. There was no patient with eosinophilic infiltration in the control group of liver transplant donors (n=27) and patients with primary sclerosing cholangitis(n = 14).CONCLUSION EC is an underdiagnosed benign etiology of SC and IBS, which has to be considered in differential diagnosis of IBS.

Safety and efficacy of laser and cold knife urethrotomy for urethral stricture

包括冷刀和激光，为尿道的苛评的背景内视镜的处理提出主要挑战到临床的实践。这二个处理的好处和缺点仍然保持争论。这篇文章试图为我们寻找了的尿道的 stricture.Methods 比较激光和冷刀 urethrotomy 的功效和安全 PubMed ( 1966-2009 )， Embase ( 1980-2009 )，控制试用的 Cochrane 中央收款机( CCRCT ， 2009 No.1 )并且为激光和是的冷刀 urethrotomy 的中国生物医学的文学数据库( CBM )为男尿道的狭窄的处理，在英语文学看。二个评论家独立地屏蔽了文学并且提取了信息。Chi 平方测试与 44 篇文章全部的 SPSS15.0.Results A 被用于统计分析， 3230 个盒子包括被检索。与激光对待的病人的成功率为冷刀与 68.5% 相比是 74.9% ，与尽管有统计上重要的差别(P=0.004 ) 的很类似的临床的结果。处于在一不同后续时间的成功率的趋势在二个组之间是类似的。处于成功率的重要差别都没为复发盒子，第一 P=0.090 和第二 P=0.459 在重复操作的组之间被发现。苛评长度越短(< 1 厘米) ，成功率是越多 higher (P < 0.0001 ) 。处于在激光和冷刀组之间的成功率的重要差别都没在既不球根也不膜的尿道，球根的 P=0.660 和膜的 P=0.477 被发现。尿不能自制，尿溢出，和尿道感染的率没显示出重要差别( P=0.259 ， P=0.938 ， P=0.653 ，分别地)尽管有是统计上不同的，为激光的 .Conclusions 成功率和冷刀是很类似的，与这些组一起，在成功有一个类似的趋势在不同后续时间评价。内视镜的干预的苛评地点和历史确实影响了处理结果，但是不是显著地不同的。二个组没在主要复杂并发症显示出重要差别。

李渔“抹倒”汤显祖辨

李渔“抹倒”汤显祖辨闻而畏李渔在《闲情偶寄》“演习部·选剧第一”中说：“汤若士之《牡丹亭》、《邯郸梦》得以盛传于世，吴石渠之《绿牡丹》、《画中人》得以偶登于场者，皆才人侥幸之事，非文至必传之常理也。若据时优本念，则愿秦皇复出，尽火文人已刻之书，止存优...