Translational gastroenterology and hepatology最新文献

Background: Patients with chronic liver disease (CLD) are more likely to have severe morbidity and mortality due to superimposed acute or chronic hepatitis B virus (HBV) infection and should receive routine vaccination against the virus. Heplisav-B is a two-dose, inactivated, yeast-derived vaccine that uses a novel immunostimulatory adjuvant. Our primary objective was to determine the efficacy of hepatitis B vaccination with Heplisav-B in patients with CLD.

Methods: This retrospective cohort analysis included patients ≥18 years old with CLD who received Heplisav-B from January 2018 to January 2021. All patients had anti-HBs <10 IU/L prior to vaccination and received two doses of Heplisav-B. Post-vaccination anti-HBs of ≥10 IU/L was considered successful vaccination. Basic demographic information, laboratory markers, and medical history were collected from the electronic health record.

Results: A total of 120 patients were included in analysis. The average age of patients was 59 years, 37% were female, and the most common etiology of liver disease was nonalcoholic fatty liver disease. Median days from 2nd vaccination to post-vaccination HBsAb levels was 121 days. 81/120 (67.5%) of patients had evidence of active immunity after receipt of Heplisav-B. On multivariable analysis, age >50 was associated with reduced odds of successful vaccination (OR =0.19, 95% CI: 0.03-0.76).

Conclusions: In patients with CLD, Heplisav-B's overall efficacy (67.5%) is greater than reports of Engerix-B (33-45%), and thus is an effective hepatitis B vaccine in this patient population, particularly in cirrhotic patients. Further studies regarding this vaccine are needed in patients with CLD and after liver transplantation.

Endoscopic mucosal resection (EMR) is a minimally invasive, specialized endoscopic technique that is useful in resecting superficial gastrointestinal lesions that are unable to be removed by standard polypectomy. This is typically accomplished using a submucosal injection that lifts the lesion away from the muscularis propria to allow for safe resection of the polyp, either via piecemeal or en bloc resection. Over the years, several techniques exist to perform EMR including conventional EMR or hot EMR, cold EMR and underwater EMR. Despite its established advantages and safety over conventional techniques such as surgery, the adoption of endoscopic resection (and thus the education and training of gastroenterology trainees) is lagging. The goal of this article is to offer a comprehensive review of the basic principles of colonic EMR. We review the concepts of optical diagnosis including the various polyp classification systems available to determine the polyp morphology and histology. We also discuss the technical aspects of performing colonic EMR. We also outline the common adverse events associated with EMR including bleeding, perforation, postpolypectomy syndrome, and residual or recurrent polyps, and discuss preventative measures that can be taken to mitigate adverse events. Lastly, we offer practical tips for trainees who want to undertake EMR in their clinical practice.

Colonoscopy has been proven to be a successful approach in both identifying and preventing colorectal cancer. The incorporation of advanced imaging technologies, such as image-enhanced endoscopy (IEE), plays a vital role in real-time diagnosis. The advancements in endoscopic imaging technology have been continuous, from replacing fiber optics with charge-coupled devices to the introduction of chromoendoscopy in the 1970s. Recent technological advancements include "push-button" technologies like autofluorescence imaging (AFI), narrowed-spectrum endoscopy, and confocal laser endomicroscopy (CLE). Dye-based chromoendoscopy (DCE) is falling out of favor due to the longer time required for application and removal of the dye and the difficulty of identifying lesions in certain situations. Narrow band imaging (NBI) is a technology that filters the light used for illumination leading to improved contrast and better visibility of structures on the mucosal surface and has shown a consistently higher adenoma detection rate (ADR) compared to white light endoscopy. CLE has high sensitivity and specificity for polyp detection and characterization, and several classifications have been developed for accurate identification of normal, regenerative, and dysplastic epithelium. Other IEE technologies, such as blue laser imaging (BLI), linked-color imaging (LCI), i-SCAN, and AFI, have also shown promise in improving ADR and characterizing polyps. New technologies, such as Optivista, red dichromatic imaging (RDI), texture and color enhancement imaging (TXI), and computer-aided detection (CAD) using artificial intelligence (AI), are being developed to improve polyp detection and pathology prediction prior to widespread use in clinical practice.

Background: The aim of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision.

Methods: Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases, EMBASE, MEDLINE, PubMed and Cochrane Library were performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software.

Results: Twenty-five comparative studies (including 2 randomised controlled trials) on 10,362 patients fulfilled the inclusion criteria. There were 4,944 patients in the transverse incision group and 5,418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development (odds ratio =0.30, 95% CI: 0.19-0.49, Z=4.88, P=0.00001). However, there was significant heterogeneity (Tau²=0.97; Chi²=109.98, df=24, P=0.00004; I²=78%) among included studies. The limitation of the study is due to lack of RCTs, this study includes both prospective and retrospective studies along with 2 RCTs which makes the meta-analysis potentially biased in source of evidence.

Conclusions: Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Background: Patients with cirrhosis have a high risk for morbidity and mortality in relation to abdominal surgery. Despite improvements in surgical techniques and intensive care, major abdominal surgery still remains a challenge. Major factors determining short- and long-term survival and perioperative complications in this patient population include severity of liver dysfunction, degree of portal hypertension (PHTN), and the presence of related complications such as ascites. Elective transjugular intrahepatic portosystemic shunt (TIPS) placement prior to surgery has been reported to improve perioperative outcomes, but available data is limited to case reports and small case series. We aimed to determine the impact of elective TIPS placement on perioperative outcomes after abdominal-pelvic surgeries in patients with cirrhosis.

Methods: We performed a retrospective chart review of patients who underwent elective TIPS and compared these patients with a cohort of cirrhotic patients who underwent any abdominal surgeries without TIPS placement. The primary outcomes were mortality at 30 days and 1 year following surgery. Other post-operative outcomes compared between the two groups, included: blood loss, worsening ascites, wound leak, infections, encephalopathy, liver decompensation, and length of hospitalization.

Results: Among 38 patients with cirrhosis who underwent abdominal surgery, 20 patients underwent pre-operative elective TIPS placement. Demographic characteristics of the two groups were comparable including age, gender, and body mass index (BMI). The median age was 62 years with a male predominance (62.5%). Both groups had similar etiologies of cirrhosis with hepatitis C virus (HCV) (34.2%) being most common. The most frequent indications for surgery were strangulated hernia (50%) in the TIPS group and acute cholecystitis (55.6%) in the non-TIPS group. Mean pre-TIPS hepato-venous portal gradient (HVPG) was 16.5 mmHg and mean post-TIPS HVPG was 7.0 mmHg. Mortality at 1 month was not statistically different between the groups (20% vs. 5.6%, respectively, P=0.19). The 1-year mortality was also not statistically different between the two groups (20% vs. 11.1%, P=0.36).

Conclusions: We found no statistically significant difference in mortality or rate of post-operative complications between patients who received pre-operative TIPS and those who did not in our age-matched cohort.