数码钢琴集体课教学方法探微

文章对数码钢琴集体课教学方法进行了探讨,并就试行中的模糊渗透法、随机试错法、能动模仿法、情景激活法等进行分析。

氟西汀治疗肥胖伴2型糖尿病的Meta分析

目的:系统评价氟西汀治疗肥胖伴2型糖尿病的临床疗效及其临床应用价值。方法:计算机检索PubMed、EMBASE、SCI、Cochrane Library、中国生物医学文献数据库、中文科技期刊全文数据库、中国期刊全文数据库及中华医学会数字化期刊,并辅以手工检索,收集氟西汀治疗肥胖伴2型糖尿病的随机对照试验,检索时间截至2009年12月。采用Cochrane系统评价手册文献质量评价标准评价纳入研究质量,用RevMan 5.0软件进行Meta分析。结果:共纳入5个RCT,各试验间基线均可比。Meta分析结果显示:氟西汀与安慰剂对比治疗肥胖伴2型糖尿病在体重减少量、空腹血糖的降低以及血清甘油三酯的降低方面的差异有统计学意义,氟西汀优于安慰剂;在血清糖化血红蛋白降低及血清胆固醇降低上两者的差异无统计学意义。在用药后的不良反应方面,两组报道较少,差异无统计学意义。结论:当前研究显示:氟西汀能够通过减少肥胖伴2型糖尿病患者的能量(特别是碳水化合物)的摄入减轻体重,也能在一定程度上降低患者的空腹血糖以及血清甘油三酯,但其不良反应也不容忽视。

瑞典药物洗脱支架与裸金属支架的长期预后比较

背景:近期研究表明,与裸金属支架相比,药物洗脱支架可能增加晚期支架血栓形成的发生率。方法:利用瑞典冠状动脉造影和血管成形术注册资料,纳入2003—2004年间6033例接受药物洗脱支架的患者和13738例接受裸金属支架的患者。随访长达3年,其中发生死亡1424例,心肌梗死2463例。进行预后分析时校正基线特征差异。结果:3年随访中,两组患者死亡和心肌梗死联合终点并无差别。

Optimization of PCR Reaction System for Random Single-strand DNA Pool in SELEX Technology

[Objective] This study aimed to optimize the PCR amplification conditions for random ssDNA pool in SELEX technology. [Method] L16（45） orthogonal experimental design was adopted for optimization of five important factors affecting PCR reaction system for random single-stranded DNA pool including Mg2＋ concentration, dNTP concentration, amount of Taq DNA polymerase, primer concentration and amount of random single-stranded DNA pool at four levels. Meanwhile, the annealing temperature and number of PCR reaction cycles were optimized to establish the optimal reaction system and PCR procedure. [Result] The optimal combination of PCR reaction system for random ssDNA pool was obtained, with a total system volume of 20 μl containing 2.0 μl of 10 × Buffer, 0.5 ng of random ssDNA pool, 2.5 mmol/L Mg2＋, 0.25 mmol/L dNTP Mixture, 0.6 μmol/L upstream and downstream primers and 1.5 U of Taq DNA polymerase; the optimal annealing temperature was 68 ℃ and the optimal number of cycles was 12. Under the above conditions, clear and stable bands with high specificity for random ssDNA pool were amplified. [Conclusion] This study laid the foundation for selection of parameters with higher specificity in SELEX technology.

降压治疗对2型糖尿病患者颈动脉内膜中层厚度进展的影响

降压治疗降低了糖尿病(DM)患者的心血管事件发生率。但是,该治疗对亚临床动脉粥样硬化的作用尚未明确。TART(曲格列酮动脉样硬化逆转试验)是一项在胰岛素依赖性2型DM成年患者中评估曲格列酮治疗对颈动脉内膜中层厚度(CIMT)进展影响的随机试验。本文报道对TART试验中降压治疗和CIMT相关性的事后队列分析的结果。

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P < 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P < 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P < 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.

痰热清注射液治疗慢性阻塞性肺疾病急性加重期的Meta分析

目的系统评价痰热清注射液治疗慢性阻塞性肺疾病急性加重期的临床疗效。方法计算机检索自建库以来至2014年5月中国学术期刊全文数据库(CNKI)、万方数据库、读秀数据库图书馆,手工检索相关杂志,搜索西药常规加痰热清注射液与单纯西药常规比较治疗慢性阻塞性肺疾病急性加重期的临床随机对照试验,经质量评价最终对纳入标准的文献采用Review Manger 5.0软件进行Meta分析。结果共纳入23个研究对象,全部为中文。Meta分析结果显示,痰热清注射液组与西药常规治疗组比较:痰热清注射液可提高临床疗效[0R=3.15,95%CI(2.41,4.12),P<0.00001];降低C反应蛋白(CRP)[WMD=-4.52,95%CI(-5.77,-3.26),P<0.00001];增加一秒用力呼气容积(FEV1)[WMD=0.29,95%CI(0.22,0.37),P=0.29]。结论痰热清注射液较西药常规治疗慢性阻塞性肺疾病急性加重期可进一步提高临床疗效,降低CRP,增加FEV1。但纳入文章质量有限,其治疗慢性阻塞性肺疾病急性加重期的疗效需要更多高质量大规模的RCT(随机对照试验)进一步验证。

New perspectives in the treatment of advanced or metastatic gastric cancer

Metastatic gastric cancer remains an incurable disease,with a relative 5-year survival rate of 7%-27%.Chemotherapy,which improves overall survival(OS) and quality of life,is the main treatment option.Metaanalysis has demonstrated that the best survival results obtained in earlier randomized studies were achieved with three-drug regimens containing a fluoropyrimidine,an anthracycline,and cisplatin(ECF).Although there has been little progress in improving median OS times beyond the 9-mo plateau achievable with the standard regimens,the availability of newer agents has provided some measure of optimism.A number of new combinations incorporating docetaxel,oxaliplatin,capecitabine,and S-1 have been explored in randomized trials.Some combinations,such as epirubicin-oxaliplatin-capecitabine,have been shown to be as effective as(or perhaps more effective than) ECF,and promising early data have been derived for S-1 in combination with cisplatin.One factor that might contribute to extending median OS is the advancement whenever possible to second-line cytotoxic treatments.However,the biggest hope for signif icant survival advances in the near future would be the combination of new targeted biological agents with existing chemotherapy f irst-line regimens.

Comparative study of laparoscopic vs open gastrectomy in gastric cancer management

AIM:To compare long-term results of gastric cancer patients undergoing laparoscopic and open gastrec-tomy in a single unit.METHODS:From February 2000 to September 2004,all patients with adenocarcinoma of the stomach were assessed to entry in this longitudinal prospective non-randomized trial.Primary endpoint was cancer-related survival and secondary endpoints were overall survival,evaluation of surgical complications and mortality.RESULTS:Fifty-eight patients were enrolled.Forty-seven patients were followed-up(range 11-103,me-dian 38 mo).Four patients were lost at follow up.Twenty-two patients underwent a laparoscopic gastric surgery(LGS)and 25 had a standard open procedure(OGS).No statistical difference was found between the two groups in terms of 5 years cancer-related mortality rate(50% vs 52%,P = 1),and 5 years overall mortal-ity rate(54.5% vs 56%,P = 1).Accordingly,cancer-related and overall survival probability by Kaplan-Meier method showed comparable results(P = 0.81 and P = 0.83,respectively).We found no differences in surgical complications in the 2 groups.There was no conversion to open surgery in this series.CONCLUSION:LGS is as effective as OGS in the man-agement of advanced gastric cancer.However LGS can-not be recommended routinely over OGS for the treat-ment of advanced gastric cancer.

Propofol vs midazolam plus fentanyl for upper gastrointestinal endomicroscopy:A randomized trial

AIM:To compare the endomicroscopic image quality of integrated confocal laser endomicroscopy(iCLE)and sedation efficacy of propofolvs midazolam plus fentanyl(M/F).METHODS:Consecutive outpatients undergoing iCLE were prospectively recruited and randomized to the propofol group(P group)or M/F group.The patient,performing endoscopist and endoscopic assistant were blinded to the randomization.The quality of endomicro-scopic images and anesthetic efficacy outcomes were blindly evaluated after iCLE examination.RESULTS:There were significantly more good quality endomicroscopic images in the propofol group than in the M/F group(72.75%vs 52.89%,P<0.001).The diagnostic accuracy for upper gastrointestinal mucosal lesions using confocal laser endomicroscopy favors the P group,although this did not reach statistical significance.Adverse events and patient assessment were not significantly different for M/F vs propofol except for more frequent intraprocedural recall with M/F.Procedure duration and sedation times were significantly longer in the M/F group,while the scores of endoscopist,anesthetist and assistant assessment were all significantly better in the P group.CONCLUSION:Sedation with propofol might increase the proportion of good quality endomicroscopic images,and may result in improved procedural efficacy and diagnostic accuracy during iCLE examination.

How we can improve patients’comfort after Milligan- Morgan open haemorrhoidectomy

AIM:To demonstrate the value of Diosmin(flavonidic fraction)in the management of post-haemorhoidectomic symptoms.METHODS:Eighty-six consecutive patients with grades ⅢandⅣacute mixed hemorrhoids admitted to the Anorectal Surgical Department of First Affiliated Hospital,Xinjiang Medical University from April 2009 to April 2010,were enrolled in this study.An observerblinded,randomized trial was conducted to compare post-haemorhoidectomic symptoms with use of Diosmin flavonidic fraction vs placebo.Eighty-six patients were randomly allocated to receive Diosmin flavonidic fraction 500 mg for 1 wk(n=43)or placebo(n=43).The Milligan-Morgan open haemorrhoidectomy was performed by a standardized diathermy excision method.Pain,bleeding,heaviness,pruritus,wound edema and mucosal discharge were observed after surgery.The postoperative symptoms and hospitalization time were recorded.RESULTS:The mean age of the Diosmin group and controls was 53.2 and 51.3 years,respectively.In Diosmin group,haemorrhoid piles were of the third degree in 33 patients and the fourth degree in 10;and in the control group,29 were of the third degree and 14 were of the fourth degree.There was no statistically significance in age,gender distribution,degree and number of excised haemorrhoid piles,and the mean duration of haemorrhoidal disease between the two groups.There was a statistically significant improvement in pain,heaviness,bleeding,pruritus from baseline to the 8th week after operation(P<0.05).Patients taking Diosmin had a shorter hospitalization stay after surgery(P< 0.05).There was also a significant improvement on the proctoscopic appearance(P<0.001).However,there was no statistical difference between the two groups in terms of wound mucosal discharge.Two patients experienced minor bleeding at the 8th week in Diosmin group,and underwent surgery.CONCLUSION:Diosmin is effective in alleviating postoperational symptoms of haemorrhoids.Therefore,it should be considered for the initial treatment after haemorrhoid surgery.However,further prospective randomized trials are needed to confirm the findings of this study.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.

Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice:A randomized trial

AIM： to compare the feasibility and patients＇ tolerance of esophagogastroduodenoscopy （EGD） using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of smallcaliber endoscopes. METHODS： One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups： conventional （C）-EGD （9.8 mm in diameter）, transnasal （TN）-EGD and transoral （TO）-EGD （5.9 mm in diameter）. Pre-EGD anxiety was measured using a 100-mm visual analogue scale （VAS）. After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation （SaO2） and heart rate （HR） were monitored during EGD. RESULTS： Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% （41/45）, 97.5% （40/41）, and 96.2% （51/53） of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer （3.11 ± 1.60 min） than TO-EGD （2.25 ± 1.45 min） and C-EGD （2.49 ± 1.64 rain） （P 〈 0.05）. The overall tolerance was higher （P 〈 0.05） and the overall discomfort was lower （P 〈 0.05） in TN-EGD group than in C-EGD group. EGD was tolerated ＂better than expected＂ in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively （P 〈 0.05）. Endoscopy was tolerated ＂worst than expected＂ in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO- EGD and C-EGD groups, respectively （P 〈 0.05）. TN-EGD caused mild epistaxis in one case, The ability to insuffiate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument （P 〈 0,001）, All biopsies performed were adequate for histological assessment. CONCLUSION： Diagnostic TN-EGD is better tolerated than C-EGD, Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved, Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

A Randomised Controlled PhaseⅡTrial of the Combination of XELOX with Thalidomide for the First-line Treatment of Metastatic Colorectal Cancer

Objective To evaluate the efficacy and safety of the combination of XELOX regimen （oxaliplatin plus capecitabine） with thalidomide for the first-line treatment of metastatic colorectal cancer （MCRC）. Methods All of the 89 patients with MCRC who fulfilled eligibility criteria were randomly assigned to treatment group （n=44） and control group （n=45）. The treatment group received a combination of XELOX with thalidomide and the control group received XELOX alone. Each patient received at least 2 cycles of treatment （1 cycle=21 d）. The primary endpoint was progression-free survival （PFS） and the secondary endpoints were objective response rate （ORR） as well as disease control rate （DCR）. Drug safety and quality of life were also assessed. Results The median PFS of the treatment and control groups were 5.6 and 5.2 months, respectively. The difference did not have a statistical significance （P=0.307）. The ORRs of the two groups also had no statistical difference （34.1% vs. 26.7%, P=0.446）. The addition of thalidomide to XELOX significantly improved the DCR （63.6% vs. 42.2%, P=0.043）. Among 24 patients with hepatic metastasis in the treatment group, 2 patients satisfied the surgical criteria after treatment but none of 23 patients in the control group did. Grade 3 or 4 constipation in patients treated with thalidomide was significantly increased （20.5% vs. 4.4%, P=0.022） but didn＇t result in treatment interruption. The rate of lethargy was increased but the difference between the two groups had no statistical significance （13,6% vs. 4.4%, P=0.130）. The quality of life had no statistical difference between the two groups. Conclusions The combination of XELOX with thalidomide for the first-line treatment of MCRC was well tolerated. Statistically significant improvement was achieved for time DCR but not for PFS.

Hemihepatic versus total hepatic inflow occlusion during hepatectomy:A systematic review and meta-analysis

AIM： To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion （HHO） compared with total hepatic inflow occlusion （THO）. METHODS： Randomized controlled trials （RCTs） co- mparing hemihepatic vascular occlusion and total he- patic inflow occlusion were included by a systematic literature search. Two authors independently assessed the trials for inclusion and extracted the data. A meta- analysis was conducted to estimate blood loss, transfu- sion requirement, and liver injury based on the levels of aspartate aminotransferase （AST） and alanine arni- notransferase （ALT）. Either the fixed effects model or random effects model was used. RESULTS- Four RCTs including 338 patients met the predefined inclusion criteria. A total of 167 patients were treated with THO and 171 with HHO. Metaanalysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean dif- ference （WMD） 342.27; 95% confidence intervals （CI） 217.28-467.26; P = 0.00001; I2 = 16%. Meta-analysis showed no significant difference between THO group and HHO group on blood loss, transfusion requirement, mortality, morbidity, operating time, ischemic duration, hospital stay, ALT levels on postoperative day 1, 3 and 7 and AST levels on postoperative day 3 and 7. CONCLUSION： Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection. However, they have less liver injury after liver resections.

Azithromycin-containing versus standard triple therapy for Helicobacter pylori eradication:A meta-analysis

AIM： To evaluate whether adding azithromycin to firstline Helicobacter pylori （H pylorl） eradication improved eradication and reduced side effects. METHODS： Eligible articles were identified by searches of electronic databases. We included all randomized trials that compared azithromycin-containing with standard triple-therapy regimens for first-line treatment of H pylori infection. Statistical analysis was performed with Review Manager 5.0.10. Sub-analyses were also performed. RESULTS： We identified 14 randomized trials （1431 patients）. Pooled Hpylori eradication rates were 72.01% （95% CI： 58.09%-85.93%） and 69.78% （95% CI： 66.47%-73.09%） for patients with or without azithromycin by intention-to-treat analysis, and the odds ratio （OR） was 1.17 （95% CI： 0.64-2.14）. The occurrence of side effects differed significantly and was 15.81% （95% CI： 12.50%-19.12%） and 25.20% （95% CI： 21.44%-28.96%） for treatment with or without azithromycin, respectively, and the summary OR was 0.58 （95% CI： 0.41-0.82）. Furthermore, the azithromycin-containing group had a lower occurrence of diarrhea, nausea and taste disturbance. CONCLUSION： Our review suggests that azithromycincontaining triple-therapy regimens could be equally effective in eradication of Hpylori compared with standard first-line triple-therapy regimens.

Ultrasound-guided Transversus Abdominis Plane Block Improves Postoperative Analgesia and Early Recovery in Patients Undergoing Retroperitoneoscopic Urologic Surgeries:A Randomized Controlled Double-blinded Trial

Objective To evaluate the effects of ultrasound-guided transversus abdominis plane(TAP) block on postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.Methods This was a randomized,controlled,double-blinded trial.Eligible patients scheduled for retroperitoneoscopic urologic surgeries were randomly assigned to two groups.Group TAP received ultrasound-guided TAP block with 0.5% ropivacaine 20 ml at 30 minutes before surgery,and Group C received TAP sham block with normal saline.All patients received retroperitoneoscopic urologic surgeries under general anesthesia.The primary outcome was the severity of pain after surgery.Secondary outcomes included opioids consumption,analgesics,postoperative nausea and vomiting,time to Foley catheter removal and to passage of flatus,length of post-anesthesia care unit stay and hospital stay.Results Eighty patients completed the study,forty cases in each group.Compared to the Group C,the Group TAP had lower visual analogue scale pain scores within two postoperative days(all P<0.05).They also had less consumption of intraoperative fentanyl(2.0±0.5 vs. 3.8±0.7 μg/kg,P<0.05),reduced incidence of postoperative rescue analgesic usage(12.5% vs. 45.0%,P<0.05),and lower incidence of postoperative nausea and vomiting within postoperative 48 hours(12.5% vs. 25.0%,P<0.05) when compared to the Group C.In addition,Group TAP had a shortened post-anesthesia care unit stay(25±8 vs. 49±12 minutes,P<0.05),and a greater proportion of patients discharged within postoperative three days(57.5% vs. 35.0%,P<0.05).Conclusion Preoperative ultrasound-guided TAP block is an effective technique to improve postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

Portal vein tumor thrombus is a bottleneck in the treatment of hepatocellular carcinoma

The effect of portal vein tumor thrombus(PVTT) on the prognosis of patients with hepatocellular carcinoma has become clear over the past several decades. However, identifying the mechanisms and performing the diagnosis and treatment of PVTT remain challenging. Therefore, this study aimed to summarize the progress in these areas. A computerized literature search in Medline and EMBASE was performed with the following combinations of search terms: "hepatocellular carcinoma" AND "portal vein tumor thrombus." Although several signal transduction or molecular pathways related to PVTT have been identified, the exact mechanisms of PVTT are still largely unknown. Many biomarkers have been reported to detect microvascular invasion, but none have proved to be clinically useful because of their low accuracy rates. Sorafenib is the only recommended therapeutic strategy in Western countries. However, more treatment options are recommended in Eastern countries, including surgery, radiotherapy(RT), transhepatic arterial chemoembolization(TACE), transarterial radioembolization(TARE), and sorafenib. Therefore, we established a staging system based on the extent of portal vein invasion. Our staging system effectively predicts the long-term survival of PVTT patients. Currently, several clinical trials had shown that surgery is effective and safe in some PVTT patients. RT,TARE, and TACE can also be performed safely in patients with good liver function. However, only a few comparative clinical trials had compared the effectiveness of these treatments. Therefore, more randomized controlled trials examining the extent of PVTT should be conducted in the future.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation(Part Ⅱ:Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be re- served for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotonin- ergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effec- tive in the treatment of patients with chronic constipa- tion. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coil who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treat- ment in dys-synergic defecation. Many surgical proce- dures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography

AIM:To determine the effectiveness of pancreatic duct(PD) stent placement for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography(ERCP) in high risk patients.METHODS:Authors conducted a single-blind,randomized controlled trial to evaluate the effectiveness of a pancreatic spontaneous dislodgement stent against post-ERCP pancreatitis,including rates of spontaneous dislodgement and complications.Authors defined high risk patients as having any of the following:sphincter of Oddi dysfunction,difficult cannulation,prior history of post-ERCP pancreatitis,pre-cut sphincterotomy,pancreatic ductal biopsy,pancreatic sphincterotomy,intraductal ultrasonography,or a procedure time of more than 30 min.Patients were randomized to a stent group(n = 60) or to a non-stent group(n = 60).An abdominal radiograph was obtained daily to assessspontaneous stent dislodgement.Post-ERCP pancreatitis was diagnosed according to consensus criteria.RESULTS:The mean age(± standard deviation) was 67.4 ± 13.8 years and the male:female ratio was 68:52.In the stent group,the mean age was 66 ± 13 years and the male:female ratio was 33:27,and in the non-stent group,the mean age was 68 ± 14 years and the male:female ratio was 35:25.There were no significant differences between groups with respect to age,gender,final diagnosis,or type of endoscopic intervention.The frequency of post-ERCP pancreatitis in PD stent and non-stent groups was 1.7%(1/60) and 13.3%(8/60),respectively.The severity of pancreatitis was mild in all cases.The frequency of post-ERCP pancreatitis in the stent group was significantly lower than in the non-stent group(P = 0.032,Fisher's exact test).The rate of hyperamylasemia were 30%(18/60) and 38.3%(23 of 60) in the stent and non-stent groups,respectively(P = 0.05,χ2 test).The placement of a PD stent was successful in all 60 patients.The rate of spontaneous dislodgement by the third day was 96.7%(58/60),and the median(range) time to dislodgement was 2.1(2-3) d.The rates of stent migration,hemorrhage,perforation,infection(cholangitis or cholecystitis) or other complicationss were 0%(0/60),0%(0/60),0%(0/60),0%(0/60),0%(0/60),respectively,in the stent group.Univariate analysis revealed no significant differences in high risk factors between the two groups.The pancreatic spontaneous dislodgement stent safely prevented post-ERCP pancreatitis in high risk patients.CONCLUSION:Pancreatic stent placement is a safe and effective technique to prevent post-ERCP pancreatitis.Therefore authors recommend pancreatic stent placement after ERCP in high risk patients.