Digestive Diseases and Sciences最新文献

Background

Anastomotic strictures following colectomy and proctectomy are a significant cause of benign lower gastrointestinal tract (LGIT) obstruction, with a reported incidence of up to 30%. Endoscopic interventions such as balloon dilation, stricturotomy, mechanical dilation, electrocautery incision, and stent placement are utilized for management. This meta-analysis aimed to evaluate the efficacy and safety of endoscopic interventions for the management of benign LGIT anastomotic strictures.

Methods

Literature search was performed for published full-text articles using the Embase, Pubmed, Web of Sciences, and Cochrane databases for endoscopic management of anastomosis strictures and related terms including endoscopic balloon dilation (EBD), stricturotomy (EST), mechanical dilation, electrocautery incision (ECI), and stent placement.

Results

A total of 1363 patients from 33 studies were included. The most common indication for anastomosis was colorectal cancer (92%). Overall technical success (ability to pass the endoscope) was achieved in 93% of cases, with immediate clinical success in 85% and sustained success in 81% at follow-up. ECI demonstrated the highest clinical success rates (98% immediate, 91% at the end of follow-up). Adverse events occurred in 6% of patients, most commonly perforation, which was most frequent with EBD. Stent placement showed high initial success but had issues with stent migration and adverse events.

Conclusion

Overall, EBD and ECI were the most effective, with ECI showing the highest success rates. Despite its technical challenges, EST was both effective and safe. This study underscores the need for further prospective research comparing various endoscopic interventions to improve management strategies for LGIT anastomotic strictures.

Background

Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear.

Aims

This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method.

Methods

We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson’s classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties.

Results

The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001).

Conclusions

Type 2–4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Graphical Abstract

Background

Previous literature suggests that rates of postoperative complications following inflammatory bowel disease (IBD) surgery differ based on race.

Aims

The purpose of this study was to examine the association between race and adverse events and wound complications in patients with IBD.

Methods

This was a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program Inflammatory Bowel Disease Collaborative from 2017 to 2022. The data was collected from 15 high-volume IBD centers across the United States. The data was analyzed using crude and multivariable logistic regressions.

Results

4284 patients were included in the study. Overall rates of adverse events and wound complications were 20.3% and 11.3%, respectively, and did not differ based on race on bivariate analysis. Rates of adverse events were 20.0% vs 24.6% vs 22.1%, p = 0.13 for white, black and other minority subjects, respectively. The adjusted odds of adverse events were higher for black subjects (1.46 [95%CI 1.0–2.1], p = 0.03) compared to white subjects. No difference in adverse events was found between other minority subjects and either black or white subjects (1.29 [0.7–2.3], p = 0.58). Race was not associated with likelihood of wound complications in the final analysis.

Conclusions

We found that a subset of black patients with IBD continue to experience more adverse events compared to white patients, primarily driven by a higher need for postoperative blood transfusion. Nonetheless, known risk factors, including comorbid conditions, decreased BMI, open surgery, and emergency surgery have a stronger association with postoperative complications than race alone.

Background

Ulcerative colitis (UC) is a chronic inflammatory condition affecting the colon, with a global incidence that is rising. Despite the increasing prevalence, effective treatment options for UC remain limited.

Methods

We utilized an NF-κB promoter dual fluorescence reporter system to screen for compounds that could inhibit p65 and IκBα phosphorylation. The anti-hypertension drug lacidipine was identified as a candidate. Its efficacy was further evaluated in a murine model of dextran sulfate sodium (DSS)-induced colitis. The analysis included the assessment of colon lesions, inflammation markers, and signal pathway activation, with a focus on NF-κB and Notch signaling.

Results

Lacidipine effectively inhibited p65 and IκBα phosphorylation in the reporter system. In the DSS-induced colitis murine model, lacidipine treatment led to a reduction in colon lesions and inflammatory markers. Target analysis showed significant enrichment of the Notch signaling pathway. Additionally, lacidipine inhibited both NF-κB and Notch activation in DSS-stimulated colons.

Conclusion

Lacidipine demonstrated a protective effect in UC, reducing inflammation and modulating key signaling pathways. These findings suggest that lacidipine could be a promising candidate for the treatment of UC.

Background and Aims

Upadacitinib is an oral selective Janus kinase (JAK) inhibitor approved in the United States for ulcerative colitis (UC) and Crohn’s disease (CD). However, data regarding its use following prior treatment with the JAK inhibitor tofacitinib is sparse. As such, we aimed to evaluate the effectiveness of upadacitinib therapy following tofacitinib exposure.

Methods

This is a multicenter retrospective study of patients with confirmed diagnosis of UC or CD who received upadacitinib after prior treatment with tofacitinib. The primary outcome of interest was patient-reported clinical improvement at first follow-up. Secondary outcome included discontinuation of corticosteroids, change in Mayo Endoscopic Score (MES) and change in inflammatory marker levels.

Results

A total of 31 patients met the inclusion criteria. Following upadacitinib initiation, 80.6% (25/31) of patients had clinical improvement, including 92.3% (24/26) of those with UC and 20% (1/5) of those with CD. Of the patients initially requiring systemic corticosteroid therapy, 80% (12/15) were able to discontinue corticosteroids. Individual mean change of fecal calprotectin was a decrease of 501.5 mcg/g ± 608.6 (P value = 0.01) while C-reactive protein decreased on average by 14.8 mg/L ± 25.3 (P value = 0.02) compared to when patients were on tofacitinib, with significant changes observed in the UC cohort. In patients with UC, individual MES after initiating upadacitinib decreased compared to prior to tofacitinib discontinuation (P value = 0.04).

Conclusion

Our study demonstrates that upadacitinib therapy in patients with prior tofacitinib exposure is associated with clinical improvement and a decrease in objective markers of inflammation in patients with UC.

Graphical Abstract