Advances in Digestive Medicine最新文献

Vedolizumab has a good safety profile for the treatment of inflammatory bowel disease. Agranulocytosis is a rare but fatal condition. Although many drugs are considered to have a high risk of agranulocytosis, no previous study has mentioned vedolizumab. A 71-year-old female with Sjogren's syndrome received vedolizumab treatment for moderate to severe ulcerative colitis. Her symptoms improved; however, leukopenia was noted after the first dose. Four days after the second dose, she complained of oral and chest pain. Agranulocytosis, oral candidiasis, and Epstein-Barr virus esophagitis with ulceration were noted. After granulocyte-colony stimulating factor treatment, the white blood cell count returned to normal and the esophageal ulcers healed. Vedolizumab is a very safe gut-selective biologic agent, but it also carries the risk of agranulocytosis.

The outcome of laparoscopic sleeve gastrectomy (LSG), one of the most common bariatric surgery (BS) procedure, may differ depending on the patient's age, gender, and postoperative follow-ups. In this study, we aimed to evaluate the efficacy of LSG technique on weight loss, obesity-associated co-morbidities and complications in patients undergoing LSG over 3 months and 1 year, regarding their age, gender, and postoperative follow-ups. The LSG associated complications in participants regarding their preoperative BMI (<39.9 and >39.9), age (30-40 and 40-50), and gender were assessed after 3 and 12 months. Besides, the remission and improvement rates of comorbid conditions in patients were examined after 12 months of LSG. Our results showed that LSG led to a significant weight loss in the resolution of obesity-associated co-morbidities and different complications after 1 year. No significant difference was found in the improvement and the resolution of obesity-associated co-morbidities according to gender. Also, the class 3 patients had significantly higher rates of hearing loss after 12 months and had higher levels of depression and brittle nails 3 months after the surgery. The younger patients also showed a significantly higher percentage of dry skin, intolerance to bread, and menstrual disorder compared to the older group. In conclusion, this study emphasized the importance and necessity of further research into the factors influencing the outcome of LSG such as age, gender, and postoperative follow-ups.

Chang et al reported the prognostic factors in single large (>5 cm) hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE).¹ Their radiological responses of complete response (CR, 8.7%), partial response (PR, 24.8%), stable disease (32.9%), and progressive disease (36%) correlated to median overall survival (OS) 71.4, 44.8, 17.7, and 14.3 months respectively. Large tumor size revealed poor prognosis factors for radiological response, while worse ALBI score and unsatisfied radiological response were two additional factors for OS.

The current article shows that low tumor burden and better liver function are the key prognostic factors, with this finding being compatible to commonly used staging systems such as BCLC,² et al. HCC screening in high-risk groups³ and anti-viral treatment for patients with hepatitis B⁴ and C⁵ are essential care modalities for liver diseases; additionally, the current study also pointed out that radiological response, an on-treatment factor, was also a significant factor of OS.

In most outcome research studies, authors have focused only on initial treatment modality and included mostly non-modifiable factors. In most guidelines,^{2, 6} treatment algorithm is the same for initial or repeat treatments. Sequential treatment and on-treatment prognostic factors are sometimes mentioned. Downstaging for curative treatments such as transplantation has been reported without consistent results,^{7, 8} while TACE-failure has been discussed in this era of targeted therapy.⁹ The concept of sequential treatment was firstly documented in treatment algorithms in the latest EASL guidelines¹⁰ where recommendations for sequential treatments for BCLC stage B and C were included. The concept of sequential treatment after TACE is gaining momentum.⁹

Although TACE is recognized as non-curative treatment in most guidelines, radiologists tend to eradicate tumors. For curative modalities, treatment response should be most adequately described as CR or non-CR after two or three sessions of TACE. In the current article, OS was related to treatment response. Up to 8.8% of patients achieved CR and gained nearly 6 years of OS, especially in patients with smaller tumor size. TACE appears to play some role in the treatment of single large HCC, and whereas surgical resection is the first priority for patients with such tumors, TACE might be an alternative modality.¹¹ The current article reported that patients with smaller tumor size should have better treatment response (<10 cm) and better OS (<7 cm).

The remaining 91.2% of non-CR patients, even PR, should undergo further intervention. This means that sequential management is an iss

A 37-year-old woman with a history of acute pancreatitis underwent abdominal ultrasound, which revealed a cystic lesion at the pancreatic tail. Ultrasound-guided cyst aspiration was performed, and the fluid analysis showed a high level of carcinoembryonic antigen (CEA, 1470 ng/mL), amylase (31 835 U/L) and lipase (102 410 U/L). Further abdominal computed tomography (CT) revealed a 6.3-cm unilocular cystic lesion with a well-defined thin wall, which can be enhanced by contrast-enhanced endoscopic ultrasound. Magnetic resonance cholangiopancreatography (MRCP) was then arranged and revealed the communication between the cyst and the main pancreatic duct (Figure 1). Pancreatic pseudocyst was initially diagnosed, and transpapillary endoscopic retrograde pancreatic stent drainage was performed for symptomatic relief.

Three months after the stent implantation, CT showed a significantly shrunken pancreatic cyst. One month after removal of the plastic stent, however, a recurrent pancreatic cyst was revealed by abdominal ultrasound. Thus, fine needle aspiration guided by contrast-enhanced endoscopic ultrasound was performed, and showed a 2.8 cm-in-diameter hypoechoic cystic tumor with a 1.1 cm-in-diameter anechoic region (Figure 2). The CEA level of the cystic fluid was up to 1470 ng/mL; pancreatic mucinous cystadenoma was thus highly suspected. The pathological report after distal pancreatectomy with splenectomy confirmed the cystic lesion as a mucinous cystadenoma in the tail of pancreas with a potential of malignant change.

The cystic lesion of our patient was initially treated as a pancreatic pseudocyst. However, the discrepancy lies in the lack of obvious risk factors for pancreatitis in this patient, such as alcohol consumption, gallstones, and hypertriglyceridemia. By contrast, pancreatic cystadenomas usually manifest abdominal pain in middle-aged women,¹ but rarely cause pancreatitis.² Elevated amylase level in serum and aspirated cystic fluid are not observed in most cases of pancreatic cystadenomas.^{3, 4} However, there are few exceptions,² as in our case, where elevated amylase level in the cystic fluid was contributed by its connection to main pancreatic duct, which may activate pancreatic enzyme and trigger acute pancreatitis. In cases of pancreatic cysts with re-expanding after drainage or incomplete drainage, pancreatic cystadenomas should be highly suspected, which should be treated surgically.^{2, 4}

The authors declare no conflicts of interest.

Written informed consent was obtained from the patient.

Type III choledochal cyst (choledochocele) is a rare disease. Therefore, some endoscopists are not familiar with the clinical feature of choledochocele. We present a choledochocele case that was difficult to diagnosed until endoscopic retrograde cholangiopancreatography was performed. A 46-year-old Taiwanese gentleman had unexplained biliary colic pain with negative findings of physical examination and normal laboratory tests. Magnetic resonance cholangiopancreatography and endoscopic ultrasonography showed dilation of common bile duct (CBD) about 1.8 cm without choledocholithiasis and a cystic lesion at distal CBD about 0.9 cm. The endoscopy showed a cystic-like bulging structure above the ampullary orifice. Cholangiography showed cystic enlargement of the intramural bile duct superior to the ampullary orifice after contrast injection. Choledochocele was proved. We performed papillotomy and biopsy of the papilla. Awareness of the endoscopic feature and management strategy of choledochoele is important, which is illustrated in this case report.

Hepatitis C virus (HCV) infection is an important public health problem, causing significant morbidity and mortality worldwide. The prevalence of HCV infections is especially high among people who inject drugs (PWID). The efficacy of direct-acting antiviral (DAA) therapy was evaluated herein. During 2019-2021, a total of 321 cases who received a full course of DAA therapy and completed a 12-week follow-up observation were studied. The most frequent genotype (GT) was GT6 (34.9%), followed by GT1a (23.4%), GT1b (14.6%), GT2 (12.1%), and GT3 (11.8%). Increase was observed in GT6 (from 29.8% in 2019 to 44.9% in 2021) and GT3 (from 9.9% in 2019 to 16.3% in 2021) over the study years. GT2 was more likely found in patients >50 years old, while GT3 was more in younger patients (both P < .05). GT3 was also more frequently associated with moderate scores of fibrosis-4 index (FIB-4) (1.45 ≤ FIB-4 ≤ 3.25, 13/38 vs 49/283; P < .05). High viral loads (>1 500 000 IU/mL) were found in 65.7% of the patients, including 21.5% showing a very high level (>6 000 000 IU/mL). Compared to other genotypes, viral loads were significantly higher in GT6 (P < .005) and lower in GT1b (P < .01). The end of treatment virologic response rate and the sustained virologic response rate at 12 weeks (SVR12) post-treatment were both 100%. Two recurrent infections with GT6 and GT2 were noted at 16-month and 3-month, respectively, after achieving SVR12. The present report provides a solid evidence for the effectiveness of DAA therapy in the treatment of hepatitis C among incarcerated PWID. We believe that appropriate DAA therapy, when incorporated with active universal screening, can achieve micro-elimination of chronic hepatitis C in incarcerated persons. Hence, the strategies should be applied to all custodial settings, especially for PWID, as an important step to eliminate hepatitis C by 2025, a goal set by the Taiwan government.

Post-sphincterotomy stricture is among the more uncommon long-term complications of preceeding endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic sphincterotomy.¹ Overall, its incidence is estimated at up to 5% in long-term follow-up, warranting revision ERCP. In lack of a standard revision procedure, endoscopic treatment warrants individualization according to patient- (anatomy-directed) and operator-related (experience, etc.) factors to appropriately choose for example, among re-do papillotomy, balloon dilation and/or temporary metal or multiple plastic stenting.^{2, 3} Specifically, re-do cutting translates into higher risks of bleeding and/or perforation, while stenting and/or dilation is associated with higher post-ERCP pancreatitis (PEP) risks, such that intensified PEP prophylaxis is indicated, as was the case in this 45-year-old female with a symptomatic post-sphincterotomy stricture.⁴ The distinct selection of the revision procedure has to be taken into account aspects of duodenal anatomy (qualifying or not for a safe re-do papillotomy), severity and length of stricture (implying candidacy for stent treatment) as well as individual and institutional experience. The current patient had undergone index ERCP 3 years earlier elsewhere including endoscopic papillotomy to allow for extraction of bile duct stones. The recent ERCP was indicated due to biliary type-pain and elevated cholestasis parameters in association with common bile duct (CBD) dilation on abdominal ultrasound. Duodenoscopy indicated an excentric and severely shrunken biliary orifice post-sphincterotomy without adequate safety plane for re-do papillotomy (no intraduodenal bile duct segment) (Figure 1). After deep-biliary cannulation, a cholangiogram was performed with CBD diameter up to 14 mm with reduced contrast media clearance. After insertion of a 35″ hydrophilic-tip guidewire, endoscopic papillary balloon dilation (EPBD) up to 10 mm was performed (Supplementary  Video). The post-interventional course was uncomplicated with complete pain and cholestasis resolution, which was maintained throughout the follow-up period of 1 year.

The author declares no conflict of interest.

Ethical approval was waived (clinical routine case); informed consent has been obtained.

A 40-year-old man with no known underlying diseases developed epigastric pain and passed tarry stools for 2 weeks. There was no noted coffee-ground vomitus. Upon arriving at the hospital, he had a hemoglobin level of 9 mg/dL. Esophagogastroduodenoscopy revealed oozing of the duodenal mucosa (Figure 1) The patient underwent blood transfusion with six units of packed red blood cells. Another episode of severe diarrhea with tarry stools and hemodynamic instability occurred after admission. However, no definite extravasation was detected on computed tomography angiography. On repeated esophagogastroduodenoscopy, the previously identified duodenal lesion kept oozing.

The oozing duodenal mucosa on the opposite side of superior duodenal angle, detected on repeated esophagogastroduodenoscopy, was classified as a Dieulafoy's lesion. Dieulafoy's lesion is a small mucosal erosion into a caliber-persistent and abnormally large submucosal artery. The lesion most commonly affects elderly men, and is typically located in the proximal stomach.¹

For the uncommon bleeder with no easily defined feeding vessels, endoscopic band ligation (EBL) was performed using the Multiple Band Ligator (Boston Scientific, The Speedband Superview Super 7, Boston, USA) (Figure 2A) to suction the bleeding target lesion into the cap, occupying the endoscopic view. The rubber band was placed around the bleeding site (Figure 2B). Twenty-seven days after the patient's discharge, repeat esophagogastroduodenoscopy showed a healing scar (Figure 2C).

Dieulafoy's lesions cause 2% of gastrointestinal hemorrhages, and only 15% of cases involved the duodenum.¹ For Dieulafoy's lesions, there is no definite consensus on the treatment and the options are dependent on the site of the lesion and available expertise. Several endoscopic techniques have been developed. Some studies have suggested that endoscopic mechanical hemostatic methods were more effective in achieving hemostasis than injection or thermal treatment.² EBL for Dieulafoy's lesions has gained increasing acceptance than hemoclipping because of favorable clinical outcome.^{3, 4} Hemoclipping is sometimes not easy to apply in duodenum when the angle of approach is tangential or when the location has no space to deploy the clip. Delayed bleeding of a residual vessel within a necrotic ulcer is problematic. In one study, about 3% of patients experienced delayed bleeding at the previous EBL site after EBL treatment.⁵

The authors declare no conflict of interest.

The study participant provided informed consent, and the study design was approved by the appropriate ethics review board.

Direct-acting antivirals (DAAs) have become an effective first-line treatment for chronic hepatitis C (CHC), and the fixed-dose combination of sofosbuvir (SOF) and velpatasvir (VEL) is one of the most important pangenotypic DAA regimen according to present treatment guideline. The association between SOF-based regimens and renal toxicity remains controversial. A total of 953 patients including 130 with estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73m² and 823 with eGFR > 60 mL/min/1.73m² receiving SOF/VEL therapy for 12 weeks were enrolled in this study. The eGFR was assessed at baseline, end of treatment (EOT), and 12 weeks after completion of the therapy (end of follow-up, EOF). The eGFR in patients with eGFR ≤ 60 mL/min/1.73m² increased from baseline (47.89 ± 10.25 mL/min/1.73m²) to EOT (51.65 ± 15.92; P < .001) and EOF (51.51 ± 14.46 mL/min/1.73m²; P < .05). The eGFR in patients with eGFR > 60 mL/min/1.73m² at baseline (91.52 ± 22.06 mL/min/1.73m²) was lower at EOT (90.37 ± 22.3; P < .05), with no difference between EOT and EOF (P = .06). Multivariable analysis showed that a higher serum albumin level was associated with a lower risk of eGFR decrease at EOT, and the patients with baseline eGFR > 60 mL/min/1.73m² were associated with a higher risk of eGFR decrease at EOF. The rates of sustained virologic response 12 weeks after treatment cessation (SVR12) were 99.2% in per-protocol analysis, and the most common adverse events were fatigue (4.7%), abdominal discomfort (4.5%), and skin itching (3.7%). In conclusion, renal function improved after the SOF/VEL treatment in patients with CHC and chronic kidney disease. Thus, SOF/VEL was safe, effective, and tolerable in these patients.

Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer burden globally; therefore, the prevention of HCC is a critical issue in public health.¹ In general, the most effective way to prevent HCC development is based on the major etiology in the carinogenesis of HCC; for example, antiviral treatment for chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.^{2, 3} However, although antiviral treatment can significantly reduce HCC risk amongst patients with chronic viral hepatitis, the risk is not completely eliminated. Therefore, other methods which can further lower HCC risk remain highly expected. For example, due to its anti-inflammatory properties, aspirin has been previously investigated for its possible chemopreventive effect in HBV- or HCV-related HCC,^{4, 5} even though antiviral treatment remains the first consideration for HCC prevention. In addition, some etiologies of HCC remain lacking effective therapies; for example, non-alcoholic fatty liver disease.⁶ In general, discovering another new way to prevent HCC development should be encouraged.

The epidemiological investigations of HCC disclose that the rates of both incidence and mortality are two to three times higher among men than among women in most regions.¹ With an obvious gender disparity, sex hormone may play an important role in the pathogenesis of HCC, therefore whether hormone replacement therapy (HRT) can reduce HCC risk in females has been highly discussed.^{7, 8} In cell and animal experiments, some genetic, biochemical, or immunological mechanisms have been explored to explain the possible HCC chemoprevention effect of HRT.⁹ For example, in HBV-related HCC, the HBV X protein and estrogen receptor-alpha complex could downregulate the mechanisms of HCC initiation or progression.¹⁰ In HCV-related HCC, estrogen was found to inhibit mature HCV production through estrogen receptor-alpha,¹¹ and the risk of HCC development may thus be reduced. However, even though experimental studies support the preventive effect of HRT, the clinical study results are not always consistent in the prevention of HCC.^{7, 12} Importantly, current clinical evidence mainly comes from observational studies, and the study findings cannot be directly deferred to a causal relationship.

In this issue of Advances in Digestive Medicine, Chang et al¹³ aimed to investigate the chemoprevention effect of HRT on HCC risk and overall survival in women with chronic hepatitis C, and some interesting findings were disclosed after a long period of follow-up. In this retrospective population-based cohort study using data from Taiwan's National Health Insurance Research Database, 1022 patients who received HRT and 10