Sleeve Gastrectomy with Duodenal Transit Bipartition (S-DTB): Preliminary Results and Technical Aspects of Its Metabolic Structure

Obesity is a significant and escalating health issue both in Brazil and globally, with over 650 million overweight adults worldwide. The treatment of obesity can be performed clinically, endoscopically or surgically;surgical treatment proves to be safe and more effective in terms of weight loss and long-term maintenance. Objective: This study aimed to monitor the progress of weight loss and comorbidity control in patients undergoing sleeve gastrectomy with duodenal bipartition. Methods: This pilot project involved 8 patients divided into 2 arms. In the first arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenoileal transit bipartition (S-RYDITB), while in the second arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenojejunal transit bipartition (S-RYDJTB). Both procedures involved Roux-en-Y reconstruction without duodenal exclusion. In S-RYDITB, the duodenal-ileal anastomosis was performed 300 cm from the ileocecal valve (ICV), creating a 250 cm common channel and a 50 cm alimentary channel. In S-RYDJTB, a biliopancreatic loop was created 200 cm from the angle of Treitz, with a 1 m alimentary channel. Results: Five patients underwent the procedures, with one undergoing S-RYDITB and four undergoing S-RYDJTB. No adverse events such as hospitalizations, readmissions, reoperations, fistulas, bleeding, pulmonary embolism, diarrhea, dumping syndrome, or hypoglycemia occurred during the study period. The mean length of hospital stay was 2 days. The average BMI decreased from 37.27 kg/m2 preoperatively to 29.48 kg/m2 after 6 months. The significant percentage of weight loss was 21.22%, with excess weight loss of 63.6%. Ninety-five percent remission of comorbidities, including hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, steatosis, and pre-diabetes. Two patients underwent sleeve gastrectomy with duodenal bipartition using a single anastomosis. Conclusion: Duodenal switch surgery has gained worldwide recognition for its safety and efficacy in treating obesity and its associated comorbidities. In efforts to maintain the positive outcomes of the classic technique while minimizing adverse effects such as malnutrition and diarrhea, modifications to the original procedure have been proposed. Among these adaptations, Sleeve gastrectomy with bipartition of duodenal transit (S-DTB) emerges as a promising variant, offering alternative strategies to optimize patients’ nutritional safety while preserving endoscopic access to the duodenum. Initial results of S-DTB, whether performed in Roux-en-Y or single anastomosis (loop) configuration without intestinal exclusions, demonstrate the procedure’s safety and effectiveness in managing obesity and its comorbidities.

Risk factors,prognostic factors,and nomograms for distant metastasis in patients with diagnosed duodenal cancer:A population-based study

BACKGROUND Duodenal cancer is one of the most common subtypes of small intestinal cancer,and distant metastasis(DM)in this type of cancer still leads to poor prognosis.Although nomograms have recently been used in tumor areas,no studies have focused on the diagnostic and prognostic evaluation of DM in patients with primary duodenal cancer.AIM To develop and evaluate nomograms for predicting the risk of DM and person-alized prognosis in patients with duodenal cancer.METHODS Data on duodenal cancer patients diagnosed between 2010 and 2019 were extracted from the Surveillance,Epidemiology,and End Results database.Univariate and multivariate logistic regression analyses were used to identify independent risk factors for DM in patients with duodenal cancer,and univariate and multivariate Cox proportional hazards regression analyses were used to determine independent prognostic factors in duodenal cancer patients with DM.Two novel nomograms were established,and the results were evaluated by receiver operating characteristic(ROC)curves,calibration curves,and decision curve analysis(DCA).RESULTS A total of 2603 patients with duodenal cancer were included,of whom 457 cases(17.56%)had DM at the time of diagnosis.Logistic analysis revealed independent risk factors for DM in duodenal cancer patients,including gender,grade,tumor size,T stage,and N stage(P<0.05).Univariate and multivariate COX analyses further identified independent prognostic factors for duodenal cancer patients with DM,including age,histological type,T stage,tumor grade,tumor size,bone metastasis,chemotherapy,and surgery(P<0.05).The accuracy of the nomograms was validated in the training set,validation set,and expanded testing set using ROC curves,calibration curves,and DCA curves.The results of Kaplan-Meier survival curves(P<0.001)indicated that both nomograms accurately predicted the occurrence and prognosis of DM in patients with duodenal cancer.CONCLUSION The two nomograms are expected as effective tools for predicting DM risk in duodenal cancer patients and offering personalized prognosis predictions for those with DM,potentially enhancing clinical decision-making.

Helicobacter pylori infection alters gastric microbiota structure and biological functions in patients with gastric ulcer or duodenal ulcer

BACKGROUND Helicobacter pylori(H.pylori)infection is closely associated with gastrointestinal diseases.Our preliminary studies have indicated that H.pylori infection had a significant impact on the mucosal microbiome structure in patients with gastric ulcer(GU)or duodenal ulcer(DU).AIM To investigate the contributions of H.pylori infection and the mucosal microbiome to the pathogenesis and progression of ulcerative diseases.METHODS Patients with H.pylori infection and either GU or DU,and healthy individuals without H.pylori infection were included.Gastric or duodenal mucosal samples was obtained and subjected to metagenomic sequencing.The compositions of the microbial communities and their metabolic functions in the mucosal tissues were analyzed.RESULTS Compared with that in the healthy individuals,the gastric mucosal microbiota in the H.pylori-positive patients with GU was dominated by H.pylori,with signi-ficantly reduced biodiversity.The intergroup differential functions,which were enriched in the H.pylori-positive GU patients,were all derived from H.pylori,particularly those concerning transfer RNA queuosine-modification and the synthesis of demethylmenaquinones or menaquinones.A significant enrichment of the uibE gene was detected in the synthesis pathway.There was no significant difference in microbial diversity between the H.pylori-positive DU patients and healthy controls.CONCLUSION H.pylori infection significantly alters the gastric microbiota structure,diversity,and biological functions,which may be important contributing factors for GU.

Endoscopic radial incision and cutting method for adult congenital duodenal webs:A case report

BACKGROUND Congenital duodenal webs are rare in adults and can lead to various symptoms such as nausea,vomiting,and postprandial fullness.The treatment for this disease is mostly surgical.Endoscopic treatment techniques have been developed and attempted for this disease.Endoscopic radial incision and cutting(RIC)techniques are reportedly very effective in benign anastomotic stricture.This case report highlights the effectiveness and safety of endoscopic RIC as a minimally invasive treatment for adult congenital duodenal webs.CASE SUMMARY A 23-year-old female patient with indigestion was referred to a tertiary hospital.The patient complained of postprandial fullness in the epigastric region.Previous physical examinations or blood tests indicated no abnormalities.Computed tomography revealed an eccentric broad-based delayed-enhancing mass-like lesion in the second portion of the duodenum.Endoscopy showed an enlarged gastric cavity and a significantly dilated duodenal bulb;a very small hole was observed in the distal part of the second portion,and scope passage was not possible.Gastrografin upper gastrointestinal series was performed,revealing an intraduodenal barium contrast-filled sac with a curvilinear narrow radiolucent rim,a typical"windsock"sign.Endoscopic RIC was performed on the duodenal web.The patient recovered uneventfully.Follow-up endoscopy showed a patent duodenal lumen without any residual stenosis.The patient reported complete resolution of symptoms at the 18-month follow-up.CONCLUSION Endoscopic RIC may be an effective treatment for congenital duodenal webs in adults.

Duodenal-jejunal bypass improves hypothalamic oxidative stress and inflammation in diabetic rats via glucagon-like peptide 1-mediated Nrf2/HO-1 signaling

BACKGROUND Type 2 diabetes mellitus(T2DM)is often accompanied by impaired glucose utilization in the brain,leading to oxidative stress,neuronal cell injury and inflammation.Previous studies have shown that duodenal jejunal bypass(DJB)surgery significantly improves brain glucose metabolism in T2DM rats,the role and the metabolism of DJB in improving brain oxidative stress and inflammation condition in T2DM rats remain unclear.AIM To investigate the role and metabolism of DJB in improving hypothalamic oxidative stress and inflammation condition in T2DM rats.METHODS A T2DM rat model was induced via a high-glucose and high-fat diet,combined with a low-dose streptozotocin injection.T2DM rats were divided into DJB operation and Sham operation groups.DJB surgical intervention was carried out on T2DM rats.The differential expression of hypothalamic proteins was analyzed using quantitative proteomics analysis.Proteins related to oxidative stress,inflammation,and neuronal injury in the hypothalamus of T2DM rats were analyzed by flow cytometry,quantitative real-time PCR,Western blotting,and immunofluorescence.RESULTS Quantitative proteomics analysis showed significant differences in proteins related to oxidative stress,inflammation,and neuronal injury in the hypothalamus of rats with T2DM-DJB after DJB surgery,compared to the T2DM-Sham groups of rats.Oxidative stress-related proteins(glucagon-like peptide 1 receptor,Nrf2,and HO-1)were significantly increased(P<0.05)in the hypothalamus of rats with T2DM after DJB surgery.DJB surgery significantly reduced(P<0.05)hypothalamic inflammation in T2DM rats by inhibiting the activation of NF-κB and decreasing the expression of interleukin(IL)-1βand IL-6.DJB surgery significantly reduced(P<0.05)the expression of factors related to neuronal injury(glial fibrillary acidic protein and Caspase-3)in the hypothalamus of T2DM rats and upregulated(P<0.05)the expression of neuroprotective factors(C-fos,Ki67,Bcl-2,and BDNF),thereby reducing hypothalamic injury in T2DM rats.CONCLUSION DJB surgery improve oxidative stress and inflammation in the hypothalamus of T2DM rats and reduce neuronal cell injury by activating the glucagon-like peptide 1 receptor-mediated Nrf2/HO-1 signaling pathway.

Packed with pills-obstructing duodenal web in the setting of intestinal malrotation:A case report

BACKGROUND The incidence of intestinal malrotation in adults has been reported to only be about 0.2%.Duodenal web as a cause of intestinal obstruction is rare,with an incidence of about 1:20000-1:40000.Furthermore,when described,these conditions are usually seen in early life and very infrequently in adulthood.CASE SUMMARY We report a case of a middle-aged woman with intestinal malrotation who presented with a three-month history of right-sided abdominal pain,early satiety,and a 22-pound weight loss.Patient underwent an esophagogastroduodenoscopy,which demonstrated numerous retained pills in a deformed first portion of the duodenum,concerning for a partial gastric outlet obstruction.An upper gastrointestinal series showed marked distention of the proximal duodenum with retained debris and the presence of a windsock sign,increasing the suspicion of a duodenal web.The patient subsequently underwent surgical intervention where a duodenal web with two lumens was noted and resected,opening the duodenum.There were over 150 pill capsules that were removed.The patient is doing well after this intervention.CONCLUSION Both intestinal malrotation and duodenal webs are infrequently encountered in the adult population.These pathologies can also present with nonspecific abdominal symptoms such as chronic abdominal pain and nausea.Hence,providers might not consider these pathologies in the differential for patients who present with vague symptoms which can lead to delay in management and increased mortality and morbidity.

Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

Metachronous primary esophageal squamous cell carcinoma and duodenal adenocarcinoma:A case report and review of literature

BACKGROUND The prevalence of multiple primary malignant neoplasms(MPMNs)is increasing in parallel with the incidence of malignancies,the continual improvement of diagnostic models,and the extended life of patients with tumors,especially those of the digestive system.However,the co-existence of MPMNs and duodenal adenocarcinoma(DA)is rarely reported.In addition,there is a lack of compre-hensive analysis of MPMNs regarding multi-omics and the tumor microenvir-onment(TME).CASE SUMMARY In this article,we report the case of a 56-year-old man who presented with a complaint of chest discomfort and abdominal distension.The patient was diagnosed with metachronous esophageal squamous cell carcinoma and DA in the Department of Oncology.He underwent radical resection and chemotherapy for the esophageal tumor,as well as chemotherapy combined with a programmed death-1 inhibitor for the duodenal tumor.The overall survival was 16.6 mo.Extensive evaluation of the multi-omics and microenvironment features of primary and metastatic tumors was conducted to:(1)Identify the reasons responsible for the poor prognosis and treatment resistance in this case;and(2)Offer novel diagnostic and therapeutic approaches for MPMNs.This case demonstrated that the development of a second malignancy may be independent of the location of the first tumor.Thus,tumor recurrence(including metastases)should be distinguished from the second primary for an accurate diagnosis of MPMNs.CONCLUSION Multi-omics characteristics and the TME may facilitate treatment selection,improve efficacy,and assist in the prediction of prognosis.Core Tip:Multiple primary malignant neoplasms(MPMNs)are increasingly prevalent in clinical practice,most frequently in the digestive system.We report a rare case of MPMN with a combination of esophageal squamous cell carcinoma and duodenal adenocarcinoma.According to PubMed-indexed literature,there are no standard guidelines or expert consensus on the etiology and comprehensive treatment.We also conducted a detailed study of the features of primary and metastatic tumors.The aim of this report was to identify the reasons responsible for the poor prognosis and treatment resistance in this case through histological data and provide new diagnostic and treatment directions for MPMNs.INTRODUCTION Multiple primary malignant neoplasms(MPMNs),also termed multiple primary cancers,refer to two or more primary tumors that occur simultaneously or sequentially in a single or multiple organs[1].According to the time interval from the diagnosis of the first tumor,MPMNs are divided into synchronous cancer(SC)(<6 mo)and metachronous cancer(MC)(≥6 mo)[2].The detection rate of the second or multiple primary tumors is also on the rise due to newer diagnostic methods and treatments,as well as the longer survival times of patients with cancer.MPMNs are most commonly reported in the digestive system;however,their occurrence in combination with duodenal adenocarcinoma(DA)is extremely rare.In this article,we describe the case of a patient who had metachronous esophageal squamous cell carcinoma(ESCC)and DA with multiple metastases.In this analysis,we thoroughly examined the multi-omics features and tumor-related immune microenvironment.OUTCOME AND FOLLOW-UP The patient was eventually followed up until clinical death on June 18,2022(Figure 2),with an overall survival 16.6 mo.

Drug-induced mucosal alterations observed during esophagogastroduodenoscopy

Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract,i.e.,the esophagus,stomach,and duodenum.These include pill-induced esophagitis,desquamative esophagitis,worsening of gastroesophageal reflux,chemotherapy-induced esophagitis,proton pump inhibitor-induced gastric mucosal changes,medication-induced gastric erosions and ulcers,pseudomelanosis of the stomach,olmesartan-related gastric mucosal inflammation,lanthanum deposition in the stomach,zinc acetate hydrate tabletinduced gastric ulcer,immune-related adverse event gastritis,olmesartan-associated sprue-like enteropathy,pseudomelanosis of the duodenum,and lanthanum deposition in the duodenum.For endoscopists,acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions.This minireview aims to provide essential information on druginduced mucosal alterations observed on esophagogastroduodenoscopy,along with representative endoscopic images.

Duodenal neuroendocrine tumor-tertiary care centre experience:A case report

BACKGROUND Neuroendocrine neoplasms(NENs)are a heterogeneous group of neoplasms arising from neuroendocrine cells,which contribute a small fraction of gastrointestinal malignancies.Duodenal neuroendocrine tumors(dNETs)represent 2%of all gastroenteropancreatic NENs.NENs are heterogeneous in terms of clinical symptoms,location,and prognosis.Non-functional NETs are mostly asymptomatic and need a high degree of clinical suspicion.Diagnosis of NETs is by endoscopic,endosonographic biopsy,and histopathological examination with immunohistochemistry staining for synaptophysin and chromogranin A.CASE SUMMARY We present case reports of 5 patients obtained over a period of 10 years in our center with dNETs.One patient had moderately differentiated NET and the remaining four had well-differentiated NET.Surveillance endoscopy was recommended in all the patients and is kept under regular follow-up after performing endoscopic therapy using endoscopic mucosal resection in 4 of them and one patient was advised to undergo a Whipple procedure.CONCLUSION Recently,the number of reported cases of NETs has increased due to advancements in diagnostic modalities and prevalence because of longer survival duration.The management differs based on the site,size,proliferation grade,and locally invasive pattern.They are slow-growing tumors with a good overall prognosis.The prognosis correlates with local lymph node status and metastasis.

Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review

AIM: To identify the most effective treatment of duodenalstump fistula(DSF) after gastrectomy for gastric cancer.METHODS: A systematic review of the literature was performed. Pub Med, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and Up To Date databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed. RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach(3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodenojejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy(32 cases) and percutaneous biliary diversion(13 cases). The median healing time in this group was 43 d. CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.

Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors(NADETs),standardized clinical management of sporadic superficial NADETs,including diagnosis,treatment,and follow-up,has not yet been established.Retrospective studies have revealed certain endoscopic findings suggestive of malignancy.Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery.The use of endoscopic treatment including endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD),for the treatment for superficial NADETs is increasing.EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection.ESD provides an excellent complete resection rate,however it remains a challenging method,considering the high risk of intraoperative or delayed perforation.Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment.Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion,which presents a risk of lymph node metastasis.Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory.Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

History of Helicobacter pylori,duodenal ulcer,gastric ulcer and gastric cancer

Helicobacter pylori(H.pylori)infection underlies gastric ulcer disease,gastric cancer and duodenal ulcer disease.The disease expression reflects the pattern and extent of gastritis/gastric atrophy(i.e.,duodenal ulcer with non-atrophic and gastric ulcer and gastric cancer with atrophic gastritis).Gastric and duodenal ulcers and gastric cancer have been known for thousands of years.Ulcers are generally non-fatal and until the 20th century were difficult to diagnose.However,the presence and pattern of gastritis in past civilizations can be deduced based on the diseases present.It has been suggested that gastric ulcer and duodenal ulcer both arose or became more frequent in Europe in the 19th century.Here,we show that gastric cancer and gastric ulcer were present throughout the 17th to 19th centuries consistent with atrophic gastritis being the predominant pattern,as it proved to be when it could be examined directly in the late 19th century.The environment before the 20th century favored acquisition of H.pylori infection and atrophic gastritis(e.g.,poor sanitation and standards of living,seasonal diets poor in fresh fruits and vegetables,especially in winter,vitamin deficiencies,and frequent febrile infections in childhood).The latter part of the 19th century saw improvements in standards of living,sanitation,and diets with a corresponding decrease in rate of development of atrophic gastritis allowing duodenal ulcers to become more prominent.In the early 20th century physician’s believed they could diagnose ulcers clinically and that the diagnosis required hospitalization for"surgical disease"or for"Sippy"diets.We show that while H.pylori remained common and virulent in Europe and the United States,environmental changes resulted in changes of the pattern of gastritis producing a change in the manifestations of H.pylori infections and subsequently to a rapid decline in transmission and a rapid decline in all H.pylori-related diseases.

Duodenal adenocarcinoma: Advances in diagnosis and surgical management

Duodenal adenocarcinoma is a rare but aggressive malignancy. Given its rarity, previous studies have traditionally combined duodenal adenocarcinoma(DA) with either other periampullary cancers or small bowel adenocarcinomas, limiting the available data to guide treatment decisions. Nevertheless, management primarily involves complete surgical resection when technically feasible. Surgery may require pancreaticoduodenectomy or segmental duodenal resection; either are acceptable options as long as negative margins are achievable and an adequate lymphadenectomy can be performed. Adjuvant chemotherapy and radiation are important components of multi-modality treatment for patients at high risk of recurrence. Further research would benefit from multiinstitutional trials that do not combine DA with other periampullary or small bowel malignancies. The purpose of this article is to perform a comprehensive review of DA with special focus on the surgical management and principles.

Short-and long-term outcomes of endoscopically treated superficial non-ampullary duodenal epithelial tumors

BACKGROUND It is widely recognized that endoscopic resection(ER) of superficial nonampullary duodenal epithelial tumors(SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation.These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short-and long-term outcomes have not been standardized yet.AIM To investigate the curability including short-and long-term outcomes of ER for SNADETs in a large case series.METHODS This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER.RESULTS In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections(EMRs)(93%) and 11 endoscopic submucosal dissections(ESDs)(7%). The median tumor diameter was 10 mm.The pathology diagnosis was adenocarcinoma(56/147, 38%), high-grade intraepithelial neoplasia(44/147, 30%), or low-grade intraepithelial neoplasia(47/147, 32%). The R0 resection rate was 68%(93/136) in the EMR group and73%(8/11) in the ESD group, respectively. Cap-assisted EMR(known as EMR-C)showed a higher rate of R0 resection compared to the conventional method of EMR using a snare(78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence.CONCLUSION Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM:To investigate endoscopic ultrasound(EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.METHODS:Records of 111 patients seen at our institution from November 1999 to July 2011 with the postoperative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed.Records of patients who underwent preoperative EUS for diagnostic purposes were identified.The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results.In addition,the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome(recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded,compared and analyzed.RESULTS:Among 111 patients with benign ampullary and duodenal adenomas,47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions.In addition,computed tomography was performed in 18 patients,endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients.There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis(FAP)/other polyposis syndromes.In 38(81%,P < 0.05) patients,EUS reliably identified absence of submucosal and muscularis invasion.In 4 cases,EUS underestimated submucosal invasion that was proven by pathology.In the other 5 patients,EUS predicted muscularis invasion which could not be demonstrated in the resected specimen.EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90%(P < 0.05).Types of resection performed included endoscopic resection in 22 cases,partial duodenectomy in 9 cases,transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases.The main post-operative final pathological results included villous adenoma(n = 5),adenoma(n = 8),tubulovillous adenoma(n = 10),tubular adenoma(n = 20) and hyperplastic polyp(n = 2).Among the 47 patients who underwent resection,8(17%,5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma,intra-abdominal abscess,wound infection,delayed gastric emptying and prolonged ileus.After median followup of 20 mo there were 6 local recurrences(13%,median follow-up = 20 mo) 4 of which were in patients with FAP.CONCLUSION:EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas.These patients can safely undergo endoscopic or local resection.

The relation between HLA-DQA1 genes and genetic susceptibility to duodenal ulcer in Wuhan Hans

AIM To study the genetic susceptibility of HLA-DQA1 alleles to duodenal ulcer in Wuhan Hans.METHODS Seventy patients with duodenalulcer and fifty healthy controls were examinedfor HLA-DQA1 genotypes.HLA-DQA1 typing wascarried out by digesting the locus specificpolymerase chain reaction amplified productswith alleles specific restriction enzymes(PCR-RFLP),i.e.,Apal Ⅰ,Bsaj Ⅰ,Hph Ⅰ,Fok Ⅰ,Mbo Ⅱ and Mnl Ⅰ.RESULTS The allele frequencies of DQA1 * 0301and DQA1 * 0102 in patients with duodenal ulcerwere significantly higher and lower respectivelythan those in healthy controls(0.40 vs 0.20,P = 0.003,mcorret = 0.024)and(0.05 vs 0.14,P = 0.012,but Pcorret】0.05),respectively.CONCLUSION DQA1 * 0301 is a susceptiblegene for duodenal ulcer in Wuhan Hans,andthere are immunogenetic differences in HLA-DQA1 locus between duodenal ulcer patients andhealthy controls.

Selection of appropriate endoscopic therapies for duodenal tumors: An open-label study, single-center experience

AIM:To determine an appropriate compartmentalization of endoscopic submucosal dissection(ESD)or endoscopic mucosal resection(EMR)for duodenal tumors.METHODS:Forty-six duodenal lesions(excluding papillary lesions)from 44 patients with duodenal tumors treated endoscopically between 2005 and 2013 were divided into the ESD and EMR groups for retrospective comparison and analysis.RESULTS:The mean age was 65±9 years(35-79years).There were 24 lesions from men and 22 from women.The lesions consisted of 6 early cancers,31adenomas and 9 neuroendocrine tumors.Lesion location was the duodenal bulb in 15 cases and the descending part of the duodenum in 31 cases.The most common macroscopic morphology was elevated type in 21 cases(45.6%).Mean tumor diameter was 11.9±9.7 mm(3-60 mm).Treatment procedure was ESD(15 cases)vs EMR(31 cases).The examined parameters in the ESD vs EMR groups were as follows:mean tumor diameter,12.9±14.3 mm(3-60 mm)vs 11.4 ±6.7 mm(4-25 mm);en bloc resection rate,86.7%vs 83.9%;complete resection rate,86.7%vs 74.2%;procedure time,86.5±63.1 min(15-217 min)vs 13.2±17.0 min(2-89 min)(P<0.0001);intraprocedural perforation,3 cases vs none(P=0.0300);delayed perforation,none in either group;postprocedural bleeding,1 case vs none;mean postoperative length of hospitalization,8.2±2.9 d(5-16 d)vs 6.1±2.0 d(2-12 d)(P=0.0067);recurrence,none vs 1 case(occurring at 7 mo postoperatively).CONCLUSION:ESD was associated with a longer procedure time and a higher incidence of intraprocedural perforation;EMR was associated with a lower rate of complete resection.

Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Efficacy of ilaprazole in the treatment of duodenal ulcers:A meta-analysis

AIM:To compare the efficacy and tolerance of ilaprazole compared with other proton pump inhibitors(PPIs)in the treatment of duodenal ulcer.METHODS:An electronic database search of Medline,Embase,the Cochrane controlled trials register,Web of Science,PubMed,and the Chinese Biomedical Literature Database(updated to July 2013),and manual searches were conducted.A meta-analysis of randomized controlled trials comparing the efficacy and tolerance of ilaprazole and other PPIs in the treatment of duodenal ulcers was performed.RESULTS:Five articles involving 1481 patients were included.The meta-analysis showed no difference in the4-wk healing rate between ilaprazole and other PPIs[89.7%vs 87.0%;relative risk(RR)=1.02;95%CI:0.98-1.06;Z=1.00;P=0.32].The results did not change in the sensitivity analyses.The meta-analysis indicated that the adverse effect rate in the ilaprazole group was lower than that in the control group,but the difference was not significant(9.7%vs 13.0%;RR=0.81;95%CI:0.60-1.07;Z=1.47;P=0.14).CONCLUSION:Ilaprazole is a highly effective and safe PPI in the treatment of duodenal ulcers.Ilaprazole can be recommended as a therapy for acid-related disorders,especially in Asian populations.