Feasibility of single-incision laparoscopic cholecystectomy for acute cholecystitis

AIM: To assess the safety of single-incision laparoscopic cholecystectomy(SILC) for acute cholecystitis.METHODS: All patients who underwent SILC at Sano Hospital(Kobe, Japan) between January 2010 and December 2014 were included in this retrospective study. Clinical data related to patient characteristics and surgical outcomes were collected from medical records. The parameters for assessing the safety of the procedure included operative time, volume of blood loss, achievement of the critical view of safety, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and duration of postoperative hospital stay. Patient backgrounds were statistically compared between those with and without conversion to laparotomy.RESULTS: A total of 100 patients underwent SILC for acute cholecystitis during the period. Preoperative endoscopic treatment was performed for suspected choledocholithiasis in 41 patients(41%). The mean time from onset of acute cholecystitis was 7.7 d. According to the Updated Tokyo Guidelines(TG13) for the severity of cholecystitis, 86 and 14 patients had grade Ⅰ and grade Ⅱ acute cholecystitis, respectively. The mean operative time was 87.4 min. The mean estimated blood loss was 80.6 mL. The critical view of safety was obtained in 89 patients(89%). Conversion laparotomy was performed in 12 patients(12%). Postoperative complications of Clavien-Dindo grade Ⅲ or greater were observed in 4 patients(4%). The mean duration of postoperative hospital stay was 5.7 d. Patients converted from SILC to laparotomy tended to have higher days after onset.CONCLUSION: SILC is feasible for acute cholecystitis; in addition, early surgical intervention may reduce the risk of laparotomy conversion.

Serrated polyps of the colon and rectum:Remove or not?

In recent years,the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway.Colorectal serrated polyps are histopathologically classified into hyperplastic polyps(HPs),sessile serrated lesions,and traditional serrated adenomas;in the serrated neoplasia pathway,the latter two are considered to be premalignant.In western countries,all colorectal polyps,including serrated polyps,apart from diminutive rectosigmoid HPs are removed.However,in Asian countries,the treatment strategy for colorectal serrated polyps has remained unestablished.Therefore,in this review,we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions≥6 mm in size,and traditional serrated adenomas of any size.

Metastatic bone cancer as a recurrence of early gastric cancer - characteristics and possible mechanisms

The surgical outcome of most early gastric cancer （EGC） is usually satisfactory. Some cases show bone metastasis even though the depth of cancer invasion is confined to the mucosa. The most frequent site for recurrence of EGC is the liver. Cases of EGC with bone metastasis are reviewed to clarify the clinicopathological characteristics of EGC giving rise to bone metastasis. Possible mechanisms and risk factors underlying this rare condition are proposed. Forty-six cases of bone metastasis from EGC are reviewed from published reports and meeting proceedings in Japan. This investigation suggests that risk factors for bone metastasis from EGC include depressed-type signet-ring cell carcinoma, poorly differentiated carcinoma, and/or the likely involvement of lymph node metastasis, even though the cancer is confined to the gastric mucosa. The risk factors do not include recurrence of EGC in the liver. We speculate that the mechanism of bone metastasis from EGC is via lymphatic channels and systemic circulation. Postoperative follow-up of cases should consider the development of bone metastasis from EGC. We propose the use of elevated alkaline phosphatase levels for the detection of bone metastasis and recommend bone scintigraphy in positive cases. 2005 The WJG Press and Elsevier Inc. All rights reserved

Prospective real-time evaluation of diagnostic performance using endocytoscopy in differentiating neoplasia from nonneoplasia for colorectal diminutive polyps(≤ 5 mm)

AIM To clarify the diagnostic performance of endocytoscopy for differentiation between neoplastic and nonneoplastic colorectal diminutive polyps.METHODS Patients who underwent endocytoscopy between October and December 2016 at Sano Hospital were prospectively recruited. When diminutive polyps(≤5 mm) were detected, the lesions were evaluated by endocytoscopy after being stained with 0.05% crystal violet and 1% methylene blue. The diminutivepolyps were classified into five categories(EC 1 a, 1 b, 2, 3 a, and 3 b). Endoscopists were asked to take a biopsy from any lesion diagnosed as EC1 b(indicator of hyperplastic polyp) or EC2(indicator of adenoma). We have assessed the diagnostic performance of endocytoscopy for EC2 and EC1 b lesions by comparison with the histopathology of the biopsy specimen. RESULTS A total of 39 patients with 63 diminutive polyps were analyzed. All polyps were evaluated by endocytoscopy. The mean polyp size was 3.3 ± 0.9 mm. Among the 63 diminutive polyps, 60 were flat and 3 were pedunculated. The mean time required for EC observation, including the time for staining with crystal violet and methylene blue, was 3.0 ± 1.9 min. Histopathologic evaluation showed that 13 polyps were hyperplastic and 50 were adenomas. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of EC2 for adenoma compared with EC1 b for hyperplastic polyp were 98.0%, 92.3%, 96.8%, 98.0% and 92.3%, respectively. There were only two cases of disagreement between the endoscopic diagnosis made by endocytoscopy and the corresponding histopathological diagnosis.CONCLUSION Endocytoscopy showed a high diagnostic performance for differentiating between neoplastic and non-neoplastic colorectal diminutive polyps, and therefore has the potential to be used for "real-time histopathology".

Effective use of the Japan Narrow Band Imaging Expert Team classification based on diagnostic performance and confidence level

Five years have passed since the Japan Narrow Band Imaging Expert Team (JNET) classification was proposed in 2014. However, the diagnostic performance of this classification has not yet been established. We conducted a retrospective study and a systematic search of Medical Literature Analysis and Retrieval System On-Line. There were three retrospective single center studies about the diagnostic performance of this classification. In order to clarify this issue, we reviewed our study and three previous studies. This review revealed the diagnostic performance in regards to three important differentiations.(1) Neoplasia from non-neoplasia;(2) malignant neoplasia from benign neoplasia;and (3) deep submucosal invasive cancer (D-SMC) from other neoplasia. The sensitivity in differentiating neoplasia from non-neoplasia was 98.1%-99.8%. The specificity in differentiating malignant neoplasia from benign neoplasia was 84.7%-98.2% and the specificity in the differentiation D-SMC from other neoplasia was 99.8%-100.0%. This classification would enable endoscopists to identify almost all neoplasia, to appropriately determine whether to perform en bloc resection or not, and to avoid unnecessary surgery. This article is the first review about the diagnostic performance of the JNET classification. Previous reports about the diagnostic performance have all been retrospective single center studies. A large-scale prospective multicenter evaluation study is awaited for the validation.

Sporadic fundic gland polyps with dysplasia or carcinoma:Clinical and endoscopic characteristics

Fundic gland polyps(FGPs)are the most common gastric polyps and have been regarded as benign lesions with little malignant potential,except in the setting of familial adenomatous polyposis.However,in recent years,the prevalence of FGPs has been increasing along with the widespread and frequent use of proton pump inhibitors(PPIs).To date,several cases of FGPs with dysplasia or carcinoma(FGPD/CAs)have been reported.In this review,we evaluated the clinical and endoscopic characteristics of sporadic FGPD/CAs.Majority of the patients with sporadic FGPD/CAs were middle-aged women receiving PPI therapy and without Helicobacter pylori(H.pylori)infection.Majority of the sporadic FGPD/CAs occurred in the body of the stomach and were sessile and small with a mean size of 5.4 mm.The sporadic FGPs with carcinoma showed redness,irregular surface structure,depression,or erosion during white light observation and irregular microvessels on the lesion surface during magnifying narrow-band imaging.In addition,sporadic FGPs,even with dysplasia,are likely to progress to cancer slowly.Therefore,frequent endoscopy is not required for patients with sporadic FGPs.However,histopathological evaluation is necessary if endoscopic findings different from ordinary FGPs are observed,regardless of their size.In the future,the prevalence of FGPs is expected to further increase along with the widespread and frequent use of PPIs and decreasing infection rate of H.pylori.Currently,it is unclear whether FGPD/CAs will also increase in the same way as FGPs.However,the trends of these lesions warrant further attention in the future.

Narrow-band imaging observation of colorectal lesions using NICE classification to avoid discarding significant lesions

AIM: To assess the risk of failing to detect diminutive and small colorectal cancers with the "resect and discard" policy.METHODS: Patients who received colonoscopy and polypectomy were recruited in the retrospective study. Probable histology of the polyps was predicted by six colonoscopists by the use of NICE classification. The incidence of diminutive and small colorectal cancersand their endoscopic features were assessed. RESULTS: In total, we found 681 cases of diminutive(1-5 mm) lesions in 402 patients and 197 cases of small(6-9 mm) lesions in 151 patients. Based on pathology of the diminutive and small polyps, 105 and 18 were non-neoplastic polyps, 557 and 154 were low-grade adenomas, 18 and 24 were high-grade adenomas or intramucosal/submucosal(SM) scanty invasive carcinomas, 1 and 1 were SM deeply invasive carcinoma, respectively. The endoscopic features of invasive cancer were classified as NICE type 3 endoscopically.CONCLUSION: The risk of failing to detect diminutive and small colorectal invasive cancer with the "resect and discard" strategy might be avoided through the use of narrow-band imaging observation with the NICE classification scheme and magnifying endoscopy.

Post-colonoscopy colorectal cancer rate in the era of highdefinition colonoscopy

AIM To investigate the post-colonoscopy colorectal cancer(PCCRC) rate for high-definition(HD) colonoscopy compared with that for standard-definition colonoscopy reported previously.METHODS Using medical records at Sano Hospital(SH) and Dokkyo Medical University Koshigaya Hospital(DMUKH), we retrospectively obtained data on consecutive patients diagnosed as having CRC between January 2010 andDecember 2015. The definition of PCCRC was diagnosis of CRC between 7 and 36 mo after initial high-definition colonoscopy that had detected no cancer, and patients were divided into a PCCRC group and a non-PCCRC group. The primary outcome was the rate of PCCRC for HD colonoscopy. The secondary outcomes were factors associated with PCCRC and possible reason for occurrence of early and advanced PCCRC.RESULTS Among 892 CRC patients, 11 were diagnosed as having PCCRC and 881 had non-PCCRC. The PCCRC rate was 1.7%(8/471) at SH and 0.7%(3/421) at DMUKH. In comparison with the non-PCCRC group, the PCCRC group had a significantly higher preponderance of smaller tumors(39 mm vs 19 mm, P = 0.002), a shallower invasion depth(T1 rate, 25.4% vs 63.6%, P = 0.01), a non-polypoid macroscopic appearance(39.0% vs 85.7%, P = 0.02) and an earlier stage(59.7% vs 90.9%, P = 0.03). Possible reasons for PCCRC were "missed or new" in 9 patients(82%), "incomplete resection" in 1(9%), and "inadequate examination'" in 1(9%). Among 9 "missed or new" PCCRC, the leading cause was non-polypoid shape for early PCCRC and blinded location for advanced PCCRC.CONCLUSION The PCCRC rate for HD colonoscopy was 0.7%-1.7%, being lower than that for standard-definition colonoscopy(1.8%-9.0%) reported previously employing the same methodology.

Asymptomatic Anisakiasis of the Colon Diagnosed and Treated by Colonoscopy

Anisakiasis can involve any part of the digestive tract, but most cases reported have involved the stomach;few reports have described colonic anisakiasis. Furthermore, asymptomatic colonic anisakiasis has been reported to be very rare. A 58-year-old Japanese male asymptomatically received colonoscopy due to a fecal occult blood testing positive, and an Anisakis larva was removed in the ascending colon. After colonoscopy, an detailed questionings concerning eating raw fish revealed that the patient ate the liver of raw filefish 21 days before the colonoscopy. Thus, questionings concerning eating the raw fish were very important and helpful for correct diagnosis. This case report demonstrated that colonic anisakiasis can be diagnosed by colonoscopy before severe complications (intestinal obstruction, perforation, and cancer development) occur. Also, biopsy forceps could be used to remove the Anisakis worms, demonstrating that diagnosis and treatment can be simultaneously performed.

<i>Citrus jabara</i>Extracts Suppress MUC5AC Mucin Production in Human Lung Epithelial Cells

In the human airway, the overproduction of MUC5AC mucin is a key feature of allergic asthma, and it induces airway narrowing and obstruction. The production of MUC5AC is regulated by several signals, but the mechanism is not completely understood. We investigated the effect of jabara, a citrus containing abundant flavonoids, on the regulation of MUC5AC production. When NCI-H292 human airway epithelial cells were cultured with jabara extracts, we found that the expression of Periodic acid-schiff stained mucin was suppressed with downregulated MUC5AC production. In human primary airway cells derived from asthmatic patients, MUC5AC production was also suppressed by jabara extracts. The treatment of cells with jabara extracts decreased ERK activation in NCI-H292 and in primary cells. These results show that jabara extracts contain some factors that suppress MUC5AC production and ERK activity and suggest that it will be useful for relieving asthma.

Short Hydration in Chemotherapy with Cisplatin plus S-1 for Advanced or Recurrent Gastric Cancer: A Retrospective Study

Background: Despite there are a few reports that assessed the S-1 + CDDP regimen with short hydration regimen for unresectable or metastatic gastric cancer, there is no consensus on the best regimen for short hydration. The aim of study was to evaluate the safety and the efficacy of S-1 plus cisplatin doublet chemotherapy with short hydration. Methods: S-1 was administered orally (p.o.) twice daily for the first 3 weeks of a 5-week cycle. Dose of S-1 administered was calculated according to the body surface area. CDDP was given as an intravenous (i.v.) infusion of 60 mg/m2 on day 8 of each cycle. Patients received the total of 1900 ml infusion containing 1000 ml of acetate Ringer’s solution as pre- and post-hydraion. 300 ml of 20% mannitol was administered as a diuretic. Results: 35 patients with unresectable or recurrent gastric cancer were enrolled. The reasons for termination of S-1 + CDDP were as follows: 21 (63.6%) by progressive disease;12 (31.4%) by toxicity. Even though 12 of 35 patients (34.2%) were discontinued S-1 + CDDP chemotherapy, only one patient was discontinued by Grade 2 of increased creatinine. TTF (time to progression) was 174 days (3 - 586 days), and the median of the total number of treatment cycles of S-1 + CDDP was 3.31. Median overall survival, as secondary endpoint, was 518 days. Conclusions: Our study suggested that the short hydration regimen is as safe and efficient as the continuous hydration regimen.

New application of endocytoscope for histopathological diagnosis of colorectal lesions

BACKGROUND The endocytoscope with ultra-high magnification(x 520)allows us to observe the cellular structure of the colon epithelium during colonoscopy,known as virtual histopathology.We hypothesized that the endocytoscope could directly observe colorectal histopathological specimens and store them as endocyto-pathological images by the endoscopists without a microscope,potentially saving the burden on histopathologists.AIM To assess the feasibility of endocyto-pathological images taken by an endoscopist as adequate materials for histopathological diagnosis.METHODS Three gastrointestinal pathologists were invited and asked to diagnose 40 cases of endocyto-pathological images of colorectal specimens.Each case contained seven endocyto-pathological images taken by an endoscopist,consisting of one loupe image,three low-magnification images,and three ultra-high magnification images.The participants chose hyperplastic polyp or low-grade adenoma for 20 cases of endocyto-pathological images(10 hyperplastic polyps,and 10 Low-grade adenomas in conventional histopathology)in study 1 and high-grade adenoma/shallow invasive cancer or deep invasive cancer for 20 cases[10 tumor in situ/T1a and 10 T1b]in study 2.We investigated the agreement between the histopathological diagnosis using the endocyto-pathological images and conventional histopathological diagnosis.RESULTS Agreement between the endocyto-pathological and conventional histopathological diagnosis by the three gastrointestinal pathologists was 100%(95%CI:94.0%–100%)in studies 1 and 2.The interobserver agreement among the three gastrointestinal pathologists was 100%,and theκcoefficient was 1.00 in both studies.CONCLUSION Endocyto-pathological images were adequate and reliable materials for histopathological diagnosis.

Study protocol of the Asian XELIRI ProjecT(AXEPT):a multinational,randomized,non-inferiority,phase Ⅲ trial of second-line chemotherapy for metastatic colorectal cancer, comparing the eicacy and safety of XELIRI with or without bevacizumab versus FOLFIRI w

Background: Capecitabine and irinotecan combination therapy(XELIRI) has been examined at various dose levels to treat metastatic colorectal cancer(m CRC). Recently, in the Association of Medical Oncology of the German Cancer Society(AIO) 0604 trial, tri?weekly XELIRI plus bevacizumab, with reduced doses of irinotecan(200 mg/m^2 on day 1) and capecitabine(1600 mg/m^2 on days 1–14), repeated every 3 weeks, has shown favorable tolerability and eicacy which were comparable to those of capecitabine and oxaliplatin(XELOX) plus bevacizumab. The doses of capecit?abine and irinotecan in the AIO trial are considered optimal. In a phase I/II study, XELIRI plus bevacizumab(BIX) as second?line chemotherapy was well tolerated and had promising eicacy in Japanese patients.Methods: The Asian XELIRI Projec T(AXEPT) is an East Asian collaborative, open?labelled, randomized, phase Ⅲ clinical trial which was designed to demonstrate the non?inferiority of XELIRI with or without bevacizumab versus standard FOLFIRI(5?fluorouracil, leucovorin, and irinotecan combination) with or without bevacizumab as second?line chemo?therapy for patients with m CRC. Patients with 20 years of age or older, histologically conirmed m CRC, Eastern Coop?erative Oncology Group performance status 0–2, adequate organ function, and disease progression or intolerance of the irst?line regimen will be eligible. Patients will be randomized(1:1) to receive standard FOLFIRI with or with?out bevacizumab(5 mg/kg on day 1), repeated every 2 weeks(FOLIRI arm) or XELIRI with or without bevacizumab(7.5 mg/kg on day 1), repeated every 3 weeks(XELIRI arm). A total of 464 events were estimated as necessary to show non?inferiority with a power of 80% at a one?sided α of 0.025, requiring a target sample size of 600 patients. The 95% conidence interval(CI) upper limit of the hazard ratio was pre?speciied as less than 1.3.Conclusion: The Asian XELIRI Projec T is a multinational phase III trial being conducted to provide evidence for XELIRI with or without bevacizumab as a second?line treatment option of mCRC.

Feature importance:Opening a soil-transmitted helminth machine learning model via SHAP

In the field of landscape epidemiology,the contribution of machine learning(ML)to modeling of epidemiological risk scenarios presents itself as a good alternative.This study aims to break with the”black box”paradigm that underlies the application of automatic learning techniques by using SHAP to determine the contribution of each variable in ML models applied to geospatial health,using the prevalence of hookworms,intestinal parasites,in Ethiopia,where they are widely distributed;the country bears the third-highest burden of hookworm in Sub-Saharan Africa.XGBoost software was used,a very popular ML model,to fit and analyze the data.The Python SHAP library was used to understand the importance in the trained model,of the variables for predictions.The description of the contribution of these variables on a particular prediction was obtained,using different types of plot methods.The results show that the ML models are superior to the classical statistical models;not only demonstrating similar results but also explaining,by using the SHAP package,the influence and interactions between the variables in the generated models.This analysis provides information to help understand the epidemiological problem presented and provides a tool for similar studies.

Frequency and distribution of neglected tropical diseases in Mozambique:a systematic review

Background:Neglected tropical diseases(NTDs)affect more than one billion people living in vulnerable conditions.In spite of initiatives recently contributing to fill NTDs gaps on national and local prevalence and distribution,more epidemiological data are still needed for effective control and elimination interventions.Main text:Mozambique is considered one of the countries with highest NTDs burden although available data is scarce.This study aims to conduct a systematic review on published available data about the burden and distribution of the different NTDs across Mozambique since January 1950 until December 2018.We identified manuscripts from electronic databases(Pubmed,EmBase and Global Health)and paper publications and grey literature from Mozambique Ministry of Health.Manuscripts fulfilling inclusion criteria were:crosssectional studies,ecological studies,cohorts,reports,systematic reviews,and narrative reviews capturing epidemiological information of endemic NTDs in Mozambique.Case-control studies,letters to editor,case reports and case series of imported cases were excluded.A total of 466 manuscripts were initially identified and 98 were finally included after the revision following PRISMA guidelines.Eleven NTDs were reported in Mozambique during the study span.Northern provinces(Nampula,Cabo Delgado,Niassa,Tete and Zambezia)and Maputo province had the higher number of NTDs detected.Every disease had their own report profile:while schistosomiasis have been continuously reported since 1952 until nowadays,onchocerciasis and cysticercosis last available data is from 2007 and Echinococcosis have never been evaluated in the country.Thus,both space and time gaps on NTDs epidemiology have been identified.Conclusions:This review assembles NTDs burden and distribution in Mozambique.Thus,contributes to the understanding of NTDs epidemiology in Mozambique and highlights knowledge gaps.Hence,the study provides key elements to progress towards the control and interruption of transmission of these diseases in the country.

Knowledge and attitudes of driver license applicants and instructors about driving of patients with epilepsy in Burkina Faso

Background:Epilepsy is the most common neurological disease in the world.The objective of the study was to determine the knowledge,attitude and practice of driver's license applicants and instructors in driving schools on epilepsy in Burkina Faso.Method:This cross-sectional study was carried out from January 7th to March 7th 2020 in 21 driving schools approved by the National Driver License Authority in the city of Ouagadougou.Fifteen driver applicants and one instructor were selected in each driving school,resulting in a total of 315 driver applicants and 21 instructors in the study.Results:The mean age of participants was 29.91±7.63 years.One of the driver applicants included in the study was once experienced a seizure attack.All respondents had heard of epilepsy.The main source of epilepsy information was from family(42.5%).Two hundred and twenty-six respondents(673%)had witnessed an epileptic seizure.A majority of participants(55.9%)believed that persons with epilepsy be not permitted to drive a motor vehicle.About 44.0% of participants thought that people with epilepsy should be permitted to drive under certain conditions.One hundred and four(30.9%)participants suggested that people with epilepsy be permitted to drive a light vehicle.One hundred and forty-one(42.0%)suggest to withdraw the driving license for lifetime if a driver had an epileptic seizure attack;while twenty-three(6.8%)participants recommended suspension of driver license for 12 months.Conclusion:Efforts should be made to improve awareness and education among license applicants and instructors on the driving by people with epilepsy.

Community‑based screening of Chagas disease among Latin American migrants in a non‑endemic country: an observational study

Background:Chagas disease is a parasitic disease endemic to Latin America,but it has become a disease of global concern due to migration fows.Asymptomatic carriers may host the parasite for years,without knowing they are infected.The aim of this study is to assess prevalence of Chagas disease and evaluate the participants’level of knowl‑edge between Latin American migrants attending a community-based screening campaign.Methods:Three community-based campaigns were performed in Alicante(Spain)in 2016,2017 and 2018,including educational chats and blood tests for Trypanosoma cruzi serology.Participants completed a questionnaire assessing knowledge about the mechanisms of transmission,disease presentation,diagnosis,and treatment.People seroposi‑tive for T.cruzi underwent diagnostic confrmation by two diferent tests.Results were analyzed by multivariable logistic regression and expressed as adjusted odds ratios(aORs),adjusting for age,sex,and time in Spain.Results:A total of 596 participants were included in the study;17%were aged under 18 years.Prevalence in adults was 11%[54/496;95%confdence interval(CI):8.3–14.5%]versus 0%among children.All but one case were in Bolivians.Diagnosis was independently associated with having been born in Bolivia(aOR:102,95%CI:13–781)and a primary school-level education(aOR:2.40,95%CI:1.14–5.06).Of 54 people diagnosed with Chagas disease(most of whom were asymptomatic),42(77.7%)returned to the clinic at least once,and 24(44.4%)received treatment.Multivariable analysis showed that coming from Argentina(aOR:13,95%CI:1.61–1188)or Bolivia(aOR:1.90,95%CI:1.19–3.39)and having received information about Chagas disease in Spain(aOR:4.63,95%CI:2.54–8.97)were associ‑ated with a good level of knowledge on the disease.Having primary level studies(aOR:0.59,95%CI:0.34–0.98)and coming from Ecuador(aOR:4.63,95%CI:2.52–847)were independently associated with a lower level of knowledge.Conclusions:Community-based interventions are a good strategy for diagnosing neglected diseases such as Chagas disease in non-endemic countries and for identifying and treating infected,asymptomatic individuals.