High-dose-rate intraluminal brachytherapy during preoperative chemoradiation for locally advanced rectal cancers

AIM:To determine the feasibility and safety of high dose rate intraluminal brachytherapy(HDR-ILBT) boost during preoperative chemoradiation for rectal cancer.METHODS:Between 2008 and 2009,thirty-six patients with locally advanced rectal cancer(≥ T3 or N+),were treated initially with concurrent capecitabine(825 mg/m2 oral twice daily) and pelvic external beam radiotherapy(EBRT)(45 Gy in 25 fractions),then were randomized to group A;HDR-ILBT group(n = 17) to receive 5.5-7 Gy×2 to gross tumor volume(GTV) and group B;EBRT group(n = 19) to receive 5.4 Gy×3 fractions to GTV with EBRT.All patients underwent total mesorectal excision.RESULTS:Grade 3 acute toxicities were registered in 12 patients(70.6%) in group A and in 8(42.1%) in group B.Complete pathologic response of T stage(ypT0) in group A was registered in 10 patients(58.8%) and in group B,3 patients(15.8%) had ypT0(P < 0.0001).Sphincter preservation was reported in 6/9 patients(66.7%) in group A and in 5/10 patients(50%) in group B(P < 0.01).Overall radiological response was 68.15% and 66.04% in Group A and B,respectively.During a median follow up of 18 mo,late grade 1 and 2 sequelae were registered in 3 patients(17.6%) and 4 patients(21.1%) in the groups A and B,respectively.CONCLUSION:HDR-ILBT was found to be effective dose escalation technique in preoperative chemoradiation for rectal cancers,with higher response rates,downstaging and with manageable acute toxicities.

Comparison of multichannel intraluminal impedance-pH monitoring and reflux scintigraphy in pediatric patients with suspected gastroesophageal reflux

AIM To evaluate the agreement of multichannel intraluminal impedance-p H monitoring(MII-p HM) and gastroesophageal reflux scintigraphy(GES) for the diagnosis of gastroesophageal reflux disease. METHODS Seventy-five consecutive patients with suspectedgastroesophageal reflux disease(GERD) underwent 24-h combined MII-p HM recording and one hour radionuclide scintigraphy during the course of the MIIpH M study. Catheters with 6 impedance channels and 1 p H sensor were placed transnasally. Impedance and p H data analysis were performed automatically and manually. For impedance monitoring, reflux was defined as a retrograde 50% drop in impedance, starting distally and propagating retrogradely to at least the next two more proximal measuring channels. Reflux index(RI, percentage of the entire record that esophageal p H is < 4.0) greater than 4.2% for p HM and number of refluxes more than 50 for 24 h for MII were accepted as positive test results. At scintigraphy, 240 frames of 15 seconds duration were acquired in the supine position. Gastroesophageal reflux was defined as at least one reflux episode in the esophagus. After scintigraphic evaluation, impedance-pH recordings and scintigraphic images were evaluated together and agreement between tests were evaluated with Cohen's kappa.RESULTS Sufficient data was obtained from 60(80%) patients(34 male, 56.7%) with a mean age of 8.7 ± 3.7 years(range: 2.5-17.3 years; median: 8.5 years). Chronic cough, nausea, regurgitation and vomiting were the most frequent symptoms. The mean time for recording of MII-pH M was 22.8 ± 2.4 h(range: 16-30 h; median: 22.7 h). At least one test was positive in 57(95%) patients. According to diagnostic criteria, GERD was diagnosed in 34(57.7%), 44(73.3%), 47(78.3%) and 51(85%) patients by means of p HM, MII, GES and MII-p HM, respectively. The observed percentage agreements/κ values for GES and p HM, GES and MII, GES and MII-p HM, and MII and p HM are 48.3%/-0.118; 61.7%/-0.042; 73.3%/0.116 and 60%/0.147, respectively. There was no or slight agreement between GES and p HM alone, MII alone or MII-p HM. p H monitoring alone missed 17 patients compared to combined MII-p HM. The addition of MII to pH monitoring increased the diagnosis rate by 50%.CONCLUSION No or slight agreement was found among p H monitoring, MII monitoring, MII-pH monitoring and GES for the diagnosis of gastroesophageal reflux disease.

Local inflammatory response to gastroesophageal reflux:Association of gene expression of inflammatory cytokines with esophageal multichannel intraluminal impedance-pH data

BACKGROUND Gene expression of inflammatory cytokines may take part in the pathophysiology of different forms of gastroesophageal reflux disease(GERD).AIM To explore gene expression of inflammatory cytokines in esophageal mucosa in patients with erosive esophagitis(EE)and non-erosive forms of GERD(NERD)and its association with data of esophageal multichannel intraluminal impedancepH(MII-pH)measurements.METHODS This was a single-center prospective study.Esophageal mucosa samples were taken from the lower part of the esophagus during endoscopy.Expression of interleukin(IL)-1β,IL-10,IL-18,tumor necrosis factorα(TNFA),toll-like receptor 4(TLR4),GATA binding protein 3(GATA3),differentiation cluster 68(CD68)andβ-2 microglobulin genes in esophageal mucosa was assessed with ImmunoQuantex assays.MII-pH measurements were performed on all the participants.Diagnosis of GERD was confirmed by the results of the MII-pH data.Based on the endoscopy,patients were allocated to the groups of EE and NERD.The control group consisted of non-symptomatic subjects with normal endoscopy and MII-pH results.We used nonparametric statistics to compare the differences between the groups.Association of expression of the mentioned genes with the results of the MII-pH data was assessed with Spearman’s rank method.RESULTS Data from 60 patients with GERD and 10 subjects of the control group were available for the analysis.Higher expression of IL-18(5.89±0.4 vs 5.28±1.1,P=0.04)and GATA3(2.92±0.86 vs 2.23±0.96,P=0.03)was found in the EE group compared to NERD.Expression of IL-1β,IL-18,TNFA,and TLR4 was lower(P<0.05)in the control group compared to EE and NERD.Esophageal acid exposure correlated with the expression of IL-1β(Spearman’s rank r=0.29),IL-18(r=0.31),TNFA(r=0.35),GATA3(r=0.34),TLR4(r=0.29),and CD68(r=0.37).Mean esophagealрНcorrelated inversely with the expression of IL-18,TNFA,GATA3,TLR4,and CD68.No association of gene expression with the number of gastroesophageal refluxes was found.CONCLUSION In patients with EE,local expression of IL-18 and GATA3 was higher compared to subjects with NERD.Esophageal acid exposure correlated directly with expression of IL-1β,IL-18,TNFA,TLR4,CD68,andβ-2 microglobulin genes.Inverse correlation was revealed between expression of IL-18,TNFA,GATA3,TLR4,and CD68 and mean esophageal pH.

First Intraluminal Temperature Measurement during Ho:YAG-Laser Exposure at an <i>In-Vitro</i>URS

Introduction: The laser is a high energy instrument which can melt metals like nitinol. So it is very important to know under which conditions it is dangerous to perform an endourologic lithotripsy. We measure the temperature increase during laser exposure in an underwater in-vitro ureter model. For comparison, temperatures with and without irrigation and with different distances from the laser fiber to the thermometer are measured. Materials and Methods: We used the Ho:YAG-laser (Vera PulseTM, Coherent) with a 365 μm laser fiber. The settings of the laser were 0.6 J with a frequency of 5 Hz which is the minimum setting for that type of laser. The experimental setup was closely aligned with the clinical situation. A metal container was filled with 0.9% sodium chloride (NaCl) solution (Temp. 36.8°) and a catheter with an inner diameter of 4 mm was attached to the rim of the container. The tip of the thermometer was attached inside the catheter through a waterproof hole. The laser fiber was guided by means of a rigid URS video device (11.5 F). We had four different settings during the measurement: 1) Distance of 0.5 cm between the laser and the thermometer;without irrigation, 2) Distance of 0.5 cm between the laser and the thermometer;with irrigation, 3) Distance of 1 cm between the laser and the thermometer;without irrigation, 4) Distance of 1 cm between the laser and the thermometer;with irrigation. Results: The maximum overall temperature was recorded in the 1) and 3) setting, both featuring no irrigation. The maximum temperature was ~50°C in both settings, with the 1) setting reaching the maximum temperature after 50 seconds and hence approximately twice as fast as the 3) setting. During measurements with a NaCl solution flow we couldn’t detect any noticeable increase in temperature, neither at short nor at long distance between the laser fiber and the thermometer. Conclusion: There is a relevant heating in the ureter beside an endourologic lithotripsy. In our model we could reproduce a maximum heating until ~50°C without irrigation and no heating with irrigation. Without irrigation there is a relevant bubble formation which should be an indicator for the surgeon to stop lithotripsy due to a temperature increase which could harm surrounding tissue.

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation:High-frequency intraluminal ultrasound study

BACKGROUND The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation(EVL)has not been established.AIM To evaluate the diagnostic correlation of esophagogastroduodenoscopy(EGD)and high-frequency intraluminal ultrasound(HFIUS)for type 1 gastric varices(GOV1)after EVL and to identify the predictability for rebleeding of EGD and HFIUS.METHODS In liver cirrhosis patients with GOV1,we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1.Endoscopic grading and red color signs were analyzed using EGD,and the largest variceal cross-sectional areas were measured using HFIUS.In addition,1-year follow-up was performed.Variceal rebleeding was defined as the presence of hematemesis,hematochezia,or melena without other evidence of bleeding on endoscopic follow-up.RESULTS In 26 patients with GOV1,variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1(r=0.36).In 17 patients who completed the 1-year follow-up,variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding,whereas EGD grading was not a predictor of subsequent rebleeding.CONCLUSION HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading,so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.

Low Profile Visualized Intraluminal Support (LVIS) Stent in Endovascular Coil Embolization of Cerebral Aneurysms: A Review

Cerebral or intracranial aneurysm is a leading cause of subarachnoid hemorrhage. It was initially treated with open surgical clipping but as rapid development of technology a less invasive endovascular coiling technique of aneurysm revolutionized the treatment. Due to tortuous anatomy of parent artery and complicated morphology and location of aneurysm there is ongoing challenge in the complete obliteration of aneurysms. To aid in the advances of treating aneurysm stent assisted endovascular coiling was introduced to give more scaffold support to parent artery and decrease events of coil protrusion from aneurysms. Many types and generation of stents were developed. One of the most recently introduced stent is low profile visualized intraluminal support (LVIS) stent. Due to its low profile nature it can be used in 0.017-inch inner diameter microcatheter and reach small and complex vessels providing high aneurysmal neck coverage which was not possible through other traditional stent. In addition, its braided design with tantalum strands and radiopaque markers make it more visible during stent placement and post procedure stent evaluation. Despite of many advantages of LVIS stent it is related to high rate of thromboembolic complications and technical complications. Aim of this review paper was to evaluate therapeutic safety, effectiveness and feasibility of LVIS stent in endovascular coil embolization of intracranial aneurysms.

Acoustic and Intraluminal Ultrasonic Technologies in the Diagnosis of Diseases in Gastrointestinal Tract: A Review

Gastrointestinal (GI) auscultation (listening to sounds from stomach and bowel) has been applied for abdominal physical assessment for many years. This article evaluates the technique involved in listening to both bowel and stomach sounds and the significance of both normal and abnormal GI auscultation findings. Moreover, intraluminal ultrasonic techniques have been widely used for gastrointestinal disease diagnosis by providing intraluminal images since 1980s, this article also reviews the existing intraluminal ultrasonic technology for diagnosing of GI disorders.

INTRALUMINAL ELASTIC CIRCULAR LIGATION FOR ESOPHAGOGASTRIC ANASTOMOSIS(INCLUDING THE CLINICAL ANALYSES OF 100 CASES)

Between 1981 and 1988, 234 cases of cancerof the esophagus or gastric cardia were treatedby resection and intraluminal elastic circularligation for esophagogastric anastomosis. Thispresent study advances the results described inour earlier study. The details of technicalrefinements are here reported, based on the

Role of intraluminal brachytherapy in palliation of biliary obstruction in cholangiocarcinoma:A brief review

Surgery is the only curative treatment for cholangiocarcinoma. However, mostpatients present with advanced disease, and hence are unresectable. Thus, theintent of treatment shifts from curative to palliative in the majority of cases.Biliary drainage with intraluminal brachytherapy is an effective means ofrelieving the malignant biliary obstruction. In this review, we discuss the role ofbrachytherapy in the palliation of obstructive symptoms in extrahepatic cholangiocarcinoma.

Management of obstructed colorectal carcinoma in an emergency setting:An update

Colorectal carcinoma is common,particularly on the left side.In 20%of patients,obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced(stage II,III or even IV).Diagnosis is based on clinical presentation,plain abdominal radiogram,computed tomography(CT),CT colonography and positron emission tomography/CT.The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes re-mains unknown.For the most common left-sided obstruction,the first choice should be either emergency surgery or endoscopic decompression by self-expen-dable metal stents or tubes.The operative plan should be either one-stage or two-stage resection.One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma(colostomy or ileostomy).Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity.Two-stage resection(Hart-mann’s procedure)is safer and the most widely used despite temporally affecting quality of life.Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing.For the less common right-sided obstruction,one-stage surgical resection is more beneficial than endoscopic decompression.The role of minimally invasive surgery(laparoscopic or robotic)is a subject of debate.Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rup-ture and subsequent septic complications.The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates.Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes.Management plans are crucial and must be individualized to better fit each case.Core Tip:Acute obstruction is common in patients with more advanced colorectal carcinoma and may be the first manifestation mainly of left-sided obstruction and in elderly individuals.Emergency decompression is mandatory.Emergency surgical resection and primary anastomosis accompanied or not accompanied by proximal defunctioning stoma must be the first treatment choice for fit patients under 70 years.Hartmann’s two-stage procedure,although more preferable,must be the second alternative choice.Emergency endoscopic self-expendable metal stents must be preferred in unfit patients as a bridge to surgery and for palliative treatment in all inoperable cases.However,these basic management principles constitute a general direction.Decision-making is important and should be individualized.

Treatment Budd-Chiari Syndrome with Balloon Dilatation and Intraluminal Stent.

We treated 33 cases of Budd-Chiari syndrome caused by locallized occlusive lesions of the inferior vena cava（IVC）with balloon dilatation and stent deployment. Of the 33,21 were male and 12 female.Complete“membranous occhislon was found in 18，incomplete"membrane" in 6.and locallized stenosis in 9.

Pathophysiology of functional heartburn based on Rome Ⅲ criteria in Japanese patients

AIM:To investigate the pathophysiology of functional heartburn(FH) in Japanese patients.METHODS:A total of 111 patients with proton pump inhibitor(PPI)-refractory non-erosive gastroesophageal reflux disease underwent intraesophageal pressure testing and 24-h multichannel intraluminal impedancep H(24MII-p H) testing.The patients also completed several questionnaires while they were receiving the PPI treatment, including the questionnaire for the diagnosis of reflux disease(QUEST), the frequency scale for the symptoms of gastroesophageal reflux disease(FSSG), the gastrointestinal symptoms rating scale(GSRS), SF-36, and the Cornell Medical Index(CMI).The subjects were classified into FH and endoscopy-negative reflux disease(ENRD) groups based on the Rome Ⅲ criteria.RESULTS:Thirty-three patients with esophageal motility disorder were excluded from this study, while 22 patients with abnormal esophageal acid exposure time(p H-POS) and 34 with hypersensitive esophagus(HE) were included in the ENRD group.The FH group included 22 patients with no reflux involvement.Sex, age, and body mass index did not differ significantly between the groups.The mean SF-36 values were < 50(normal) for all scales in these groups, with no significant differences.The GSRS scores in these groups were not different and showed overlap with other gastrointestinal symptoms.The QUEST and the FSSG scores did not differ significantly between the groups.Neuroticism was diagnosed using the CMI questionnaire in 17 of the 78 included subjects within the p H-POS(n=4),HE(n=8),and FH(n=5)groups,with no significant differences.CONCLUSION:Clinical characteristics of the FH and PPI-refractory ENRD groups were similar.Therefore,esophageal function should be examined via manometry and 24MII-p H testing to differentiate between them.

Disagreement between symptom-reflux association analysis parameters in pediatric gastroesophageal reflux disease investigation

AIM: To assess the agreement within 3 commonly used symptom-reflux association analysis (SAA) parameters investigating gastroesophageal reflux disease (GERD) in infants. METHODS: Twenty three infants with suspected GERD were included in this study. Symptom index (SI), Symptom sensitivity index (SSI) and symptom association probability (SAP) related to cough and irritability were calculated after 24 h combined pH/multiple intraluminal impedance (MII) monitoring. Through defined cutoff values, SI, SSI and SAP values are differentiated in normal and abnormal, whereas abnormal values point towards gastroesophageal reflux (GER) as the origin of symptoms. We analyzed the correlation and the concordance of the diagnostic classification of these 3 SAA parameters.RESULTS: Evaluating the GER-irritability association, SI, SSI and SAP showed non-identical classification of normal and abnormal cases in 39.2% of the infants. When irritability was taken as a symptom, there was only a poor inter-parameter association between SI and SSI, and between SI and SAP (Kendall’s tau b = 0.37, P < 0.05; Kendall’s tau b = 0.36, P < 0.05, respectively). Evaluating the GER-cough association, SI, SSI and SAP showed non-identical classification of normal and abnormal cases in 52.2% of the patients. When cough was taken as a symptom, only SI and SSI showed a poor inter-parameter association (Kendall’s tau b = 0.33, P < 0.05). CONCLUSION: In infants investigated for suspected GERD with pH/MII-monitoring, SI, SSI and SAP showed a poor inter-parameter association and important dis-agreements in diagnostic classification. These limitations must be taken into consideration when interpreting the results of SAA in infants.

Acid and non-acid reflux in patients refractory to proton pump inhibitor therapy:Is gastroparesis a factor?

AIM:To determine whether an increased number and duration of non-acid reflux events as measured using the multichannel intraluminal impedance pH(MII-pH)is linked to gastroparesis(GP).METHODS:A case control study was conducted in which 42 patients undergoing clinical evaluation for continued symptoms of gastroesophageal reflux disease(both typical and atypical symptoms)despite acid suppression therapy.MII-pH technology was used over 24 h to detect reflux episodes and record patients’symptoms.Parameters evaluated in patients with documented GP and controls without GP by scintigraphy included total,upright,and supine number of acid and non-acid reflux episodes(pH<4 and pH>4,respectively),the duration of acid and non-acid reflux in a 24-h period,and the number of reflux episodes lasting longer than 5 min.RESULTS:No statistical difference was seen between the patients with GP and controls with respect to the total number or duration of acid reflux events,total number and duration of non-acid reflux events or the duration of longest reflux episodes.The number of nonacid reflux episodes with a pH>7 was higher in subjects with GP than in controls.In addition,acid reflux episodes were more prolonged(lasting longer than 5min)in the GP patients than in controls;however,these values did not reach statistical significance.Thirty-five patients had recorded symptoms during the 24 h study and of the 35 subjects,only 9%(n=3)had a positive symptom association probability(SAP)for acid/non-acid reflux and 91%had a negative SAP.CONCLUSION:The evaluation of patients with a documented history of GP did not show an association between GP and more frequent episodes of non-acid reflux based on MII-pH testing.

Endovascular treatment of diabetic foot ischemic ulcer–Technical review

This article is a technical review of the common techniques used in the treatment of lower-limb occlusive arterial disease associated with diabetes.The techniques described here reflect the author’s own practice and are methods that the author finds helpful in avoiding complications and in making the technical aspects of the procedures easier.

Redefining the properties of an osmotic agent in an intestinal-specific preservation solution

AIM: To investigate the effects of dextrans of various molecular weights (Mw) during a 12 h cold storage time-course on energetics, histology and mucosal infiltration of fluorescein isothiocyanate (FITC)-dextran. METHODS: Rodent intestines were isolated and received a standard University of Wisconsin vascular flush followed by intraluminal administration of a nutrientrich preservation solution containing dextrans of varying Mw: Group D1, 73 kdal; Group D2, 276 kdal; Group D3, 534 kdal; Group D4, 1185 kdal; Group D5, 2400 kdal. RESULTS: Using FITC-labeled dextrans, fluorescent micrographs demonstrated varying degrees of mucosal infiltration; lower Mw (groups D1-D3: 73-534 kdal) dextrans penetrated the mucosa as early as 2 h, whereas the largest dextran (D5: 2400 kdal) remained captive within the lumen and exhibited no permeability even after 12 h. After 12 h, median injury grades ranged from 6.5 to 7.5 in groups D1-D4 (73-1185 kdal) representing injury of the regenerative cryptal regions and submucosa; this was in contrast to group D5 (2400 kdal) which exhibited villus denudation (with intact crypts) corresponding to a median injury grade of 4 (P < 0.05). Analysis of tissue energetics reflected a strong positive correlation between Mw and adenosine triphosphate (r 2 = 0.809), total adenylates (r 2 = 0.865) and energy charge (r 2 = 0.667).CONCLUSION: Our data indicate that dextrans of Mw > 2400 kdal act as true impermeant agents during 12 h ischemic storage when incorporated into an intraluminal preservation solution.

Randomized, double-blinded, placebo-controlled trial evaluating simethicone pretreatment with bowel preparation during colonoscopy

BACKGROUND The presence of small air bubbles and foam are an impediment to a successful colonoscopy. They impair an endoscopist’s view and diminish the diagnostic accuracy of the study. This has been particularly noted to be of concern with the switch to lower volume polyethylene glycol (PEG) and bisacodyl combination preparation. AIM To evaluate the effect of oral simethicone addition to bowel preparation on intraluminal bubbles reduction during colonoscopy. METHODS Described is a prospective, randomized, multi-center, double-blinded, placebocontrolled study to evaluate the use of premixed simethicone formulation with split-regimen, low-volume PEG-bisacodyl combination bowel preparation for 168 outpatients undergoing screening, surveillance, and diagnostic colonoscopies. Primary outcome includes evaluation of bubbles during colonoscopy graded using the Intraluminal Bubbles Scale. Secondary outcomes include evaluation of the Boston Bowel Preparation Scale (BBPS), total number of polyps, polyp size differentiation, polyp laterality, adenoma detection, mass detection, cecal insertion time, withdrawal time, and patient-reported adverse events. RESULTS Higher Intraluminal Bubbles grades III and IV (less than 75% of the mucosa cleared of bubbles/foam requiring intervention with simethicone infused wash) were detected in the placebo group [Simethicone n = 4/84 vs Placebo n = 20/84 (P = 0.007)]. BBPS total score was 7.42 [standard deviation (SD)=± 1.51] in the simethicone group and 7.28 (SD =± 1.44) in the placebo group (P = 0.542) from a total of 9. Significantly higher number of adenomas were detected in the simethicone group (P = 0.001). CONCLUSION The addition of simethicone to bowel preparation is well advised for its antifoaming properties. The results of this study suggest that addition of oral simethicone can improve bowel wall visibility.

Pre-lung transplant measures of reflux on impedance are superior to p H testing alone in predicting early allograft injury

AIM:To evaluate pre-lung transplant acid reflux on p H-testing vs corresponding bolus reflux on multichannel intraluminal impedance(MII) to predict early allograft injury.METHODS:This was a retrospective cohort study of lung transplant recipients who underwent pretransplant combined MII-p H-testing at a tertiary care center from January 2007 to November 2012. Patients with pre-transplant fundoplication were excluded. Time-to-event analysis was performed using a Cox proportional hazards model to assess associations between measures of reflux on MII-p H testing and early allograft injury. Area under the receiver operating characteristic(ROC) curve(c-statistic) of the Cox model was calculated to assess the predictive value of each reflux parameter for early allograft injury. Six p H-testing parameters and their corresponding MIImeasures were specified a priori. The p H parameters were upright,recumbent,and overall acid reflux exposure; elevated acid reflux exposure; total acid reflux episodes; and acid clearance time. The corresponding MII measures were upright,recumbent,and overall bolus reflux exposure; elevated bolus reflux exposure; total bolus reflux episodes; and bolus clearance time.RESULTS:Thirty-two subjects(47% men,mean age:55 years old) met the inclusion criteria of the study. Idiopathic pulmonary fibrosis(46.9%) repres e n t e d t h e m o s t c o m m o n p u l m o n a r y d i a g n o s i s leading to transplantation. Baseline demographics,pre-transplant cardiopulmonary function,number of lungs transplanted(unilateral vs bilateral),and posttransplant proton pump inhibitor use were similar between reflux severity groups. The area under the ROC curve,or c-statistic,of each acid reflux parameter on pre-transplant p H-testing was lower than its bolus reflux counterpart on MII in the prediction of early allograft injury. In addition,the development of early allograft injury was significantly associated with three pre-transplant MII measures of bolus reflux:overall reflux exposure(HR = 1.18,95%CI:1.01-1.36,P = 0.03),recumbent reflux exposure(HR = 1.25,95%CI:1.04-1.50,P = 0.01) and bolus clearance(HR = 1.09,95%CI:1.01-1.17,P = 0.02),but not with any p Htesting parameter measuring acid reflux alone.CONCLUSION:Pre-transplant MII measures of bolus reflux perform better than their p H-testing counterparts in predicting early allograft injury post-lung transplantation.

Endoscopic resection of bronchial mucoepidermoid carcinoma in a young adult man: A case report and review of literature

BACKGROUND Primary tracheobronchial mucoepidermoid carcinoma(MEC),derived from salivary mucus glands,is an uncommon neoplasm in adults.At present,surgery is still the preferred treatment for adult bronchial MEC,although it may cause significant trauma and loss of lung function.Here,we report a patient with endobronchial MEC who received the interventional bronchoscopic therapy to remove the neoplasm and no recurrence occurred during follow-up.CASE SUMMARY A 28-year-old man was admitted to our unit with mild hemoptysis for 3 d.Physical examination did not show any abnormal signs,and the serological indexes were all in the normal range.Chest computed tomography(CT)indicated an intraluminal nodule in the bronchus intermedius with homogeneous density and a well-defined margin.Upon fiberoptic bronchoscopy,an endobronchial pedunculated polypoid was discovered without submucosal involvement.As the neoplasm was confined to the bronchus,interventional bronchoscopy was performed to remove the mass by high-frequency electric knife and laser resection.Tissue was sampled and histopathological examination confirmed the diagnosis of low-grade MEC.As the proliferation index was low,no further treatment was given.During 2 years of follow-up,the patient’s condition was good and no relapse was discovered under fluorescence bronchoscopy or CT scan.CONCLUSION Interventional bronchoscopy can be considered for treatment of low-grade bronchial MEC,with few complications and preserved lung function.

Choledochoscope with stent placement for treatment of benign duodenal strictures:A case report

BACKGROUND Endoscopically or fluoroscopically guided dilation is a safe and effective alternative to surgery for patients with benign strictures of the gastric outlet.CASE SUMMARY We describe two cases where a novel approach with a Spyglass~? choledochoscope in assessing the extent of benign duodenal strictures and aiding in placement of duodenal stents for treatment of the strictures. Choledochoscope-guided wire and stent placement was successful in all cases, leading to symptom resolution related to benign duodenal obstruction. No major adverse events were observed.CONCLUSION Choledochoscope-guided assessment and endoscopic therapy is a viable approach in relieving duodenal obstruction, if the conventional combined fluoroscopic and endoscopic methods fail.