Biliary fistula and late recurrence of liver hydatid cyst: Role of cysto-biliary communication: A prospective multicenter study

BACKGROUND

Hydatid cyst disease (HCD) is common in certain locations. Surgery is associated with postoperative biliary fistula (POBF) and recurrence. The primary aim of this study was to identify whether occult cysto-biliary communication (CBC) can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase (ALP) levels in predicting POBF and recurrent HCD.

AIM

To identify whether occult CBC can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.

METHODS

From September 2010 to September 2016, a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty. Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.

RESULTS

There was a highly statistically significant association (P ≤ 0.001) between cystic fluid biochemical indices and the development of biliary complications (of 16 patients with POBF, 15 patients had high cyst fluid bilirubin and ALP levels), where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications. There was a highly statistically significant association (P ≤ 0.001) between biliary complications, biochemical indices, and the occurrence of recurrent HCD (of 30 patients with recurrent HCD, 15 patients had high cyst fluid bilirubin and ALP; all 16 patients who had POBF later developed recurrent HCD), where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts, respectively.

CONCLUSION

Occult CBC can predict recurrent HCD. Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.

Correlation of Epstein-Barr virus infection with pathological characteristics of colorectal cancer and its short-term prognosisr after chemotherapy

BACKGROUND

In recent years, studies have demonstrated that Epstein-Barr virus (EBV) may play a role in the occurrence of colorectal cancer. Currently, clinical reports on EBV involved in tumor cell proliferation, differentiation, and migration are mainly concentrated in gastric cancer, nasopharyngeal carcinoma, B-cell lymphoma, etc., which have the functions of promoting tumor development and regulating the body's immune microenvironment. The relationship between EBV and colorectal cancer has been less explored.

AIM

To analyze the correlation between EBV infection and the pathological characteristics of colorectal cancer as well as its short-term prognosis after chemotherapy to provide reference for its clinical diagnosis, treatment, and prognosis evaluation.

METHODS

A total of 45 EBV-positive and 180 EBV-negative colorectal cancer patients admitted to Jinhua Central Hospital from May 2021 to March 2024 were selected. The relationship between EBV infection and the clinicopathological characteristics of colorectal cancer was analyzed, and the EBV-DNA load was compared in patients with different pathological characteristics in the EBV-positive group. The correlation between EBV-DNA load and pathological characteristics of colorectal cancer was analyzed. The short-term prognosis of colorectal cancer patients after chemotherapy was recorded. The pathological characteristics and EBV infection status was compared in patients with different short-term prognoses. The factors that affect the patients' short-term prognosis were analyzed. The predictive value of EBV infection and pathological characteristics for the short-term prognosis of colorectal cancer patients was analyzed.

RESULTS

The proportions of patients with stage Ⅲ + Ⅳ, low differentiation, deep invasion (T3 + T4), and lymph node metastasis in the EBV-positive group were higher than those of the EBV-negative group (P < 0.05). EBV-DNA load differed significantly in patients with different degrees of differentiation, infiltration depth, tumor stages, and lymph node metastasis in the EBV-positive group (P < 0.05). EBV-DNA load in patients with EBV-infected colorectal cancer was negatively correlated with the degree of differentiation, and positively correlated with tumor stage, lymph node metastasis, and infiltration depth (P < 0.05). Lymph node metastasis, degree of differentiation, tumor stage, infiltration depth, and EBV infection were all independent factors affecting the short-term prognosis of colorectal cancer patients (P < 0.05). The area under the curve of the combination of tumor stage, infiltration depth, lymph node metastasis, degree of differentiation, and EBV infection in predicting the short-term prognosis of colorectal cancer patients was 0.882 (95% confidence interval: 0.832-0.921), with a sensitivity of 84.93% and specificity of 91.45% (P < 0.05).

CONCLUSION

EBV infection is significantly correlated with tumor stage, differentiation degree, depth of invasion, lymph node metastasis, and short-term prognosis after chemotherapy in colorectal cancer patients. The combination of pathological characteristics with EBV detection has high predictive value for the short-term prognosis of colorectal cancer patients.

Left bundle branch pacing cardiac resynchronization therapy vs biventricular pacing cardiac resynchronization therapy–time to write a requiem for biventricular pacing-cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalizations and all-cause mortality in patients with HF with reduced ejection fraction with left bundle branch (LBB) block. Biventricular pacing (BVP) is considered the gold standard for achieving CRT; however, approximately 30%–40% of patients do not respond to BVP-CRT. Recent studies have demonstrated that LBB pacing (LBBP) produces remarkable results in CRT. In this meta-analysis, LBBP-CRT showed better outcomes than conventional BVP-CRT, including greater QRS duration reduction and left ventricular ejection fraction improvement, along with consistently lower pacing thresholds on follow-up. Additionally, there was a greater reduction in New York Heart Association class and brain natriuretic peptide levels. This study contributes to the growing body of encouraging data on LBBP-CRT from recent years. With ongoing technological advancements and increasing operator expertise, the day may not be far when LBBP-CRT becomes the standard of care rather than the exception.

Strain- and sex-dependent variability in hepatic microcirculation and liver function in mice

BACKGROUND

The integrity and functionality of the hepatic microcirculation are essential for maintaining liver health, which is influenced by sex and genetic background. Understanding these variations is crucial for addressing disparities in liver disease outcomes.

AIM

To investigate the sexual dimorphism and genetic heterogeneity of liver microcirculatory function in mice.

METHODS

We assessed hepatic microhemodynamics in BALB/c, C57BL/6J, and KM mouse strains using laser Doppler flowmetry and wavelet analysis. We analyzed the serum levels of alanine transaminase, glutamic acid aminotransferase, total bile acid, total protein, alkaline phosphatase, and glucose. Histological and immunohistochemical staining were employed to quantify microvascular density and the expression levels of cluster of differentiation (CD) 31, and estrogen receptor α, and β. Statistical analyses, including the Mantel test and Pearson correlation, were conducted to determine the relationships among hepatic function, microcirculation, and marcocirculation between different sexes and across genetic backgrounds.

RESULTS

We identified sex-based disparities in hepatic microhemodynamics across all strains, with males exhibiting higher microvascular perfusion and erythrocyte concentration, but lower blood velocity. Strain-specific differences were evident, particularly in the endothelial oscillatory characteristics of the erythrocyte concentration. No sex-dependent differences in estrogen receptor expression were observed, while significant variations in CD31 expression and microvascular density were observed. The correlations highlighted relationships between hepatic microhemodynamics and liver function indicators.

CONCLUSION

Our findings indicate the influence of genetic and sex differences on hepatic microcirculation and liver function, highlighting the necessity of incorporating both genetic background and sex into hepatic physiology studies and potential liver disease management strategies.

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM

To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT).

METHODS

Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m).

RESULTS

SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00).

CONCLUSION

SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Clinical study of acupuncture combined with surface anesthesia using proparacaine in geriatric cataract phacoemulsification

BACKGROUND

During anesthesia administration for cataract surgery, low pH of proparacaine may induce pain or complications such as corneal damage and poor wound healing, with the use of additional drops intraoperatively increasing the risk of complications. Accordingly, there is a clinical need for adjuncts to local anesthesia needs to improve the efficiency of anesthesia and reduce the required amount of intraoperative proparacaine.

AIM

To identify a method of anesthesia for geriatric cataract phacoemulsification that provides more efficient analgesia and improves clinical efficacy.

METHODS

A total of 130 geriatric patients with cataracts who attended Hebei Eye Hospital from December 2020 to December 2022 were included in the present study. Patients were divided into the proparacaine surface anesthesia (SA) group (65 cases) and the compound acupuncture-medicine anesthesia group (CAMA group, 65 cases). Patients in the CAMA group were provided acupuncture analgesia in addition to SA. Preoperative anxiety [Self-Rating Anxiety Scale (SAS) score and state anxiety inventory (SAI) score], intraoperative stress, vital signs, analgesia, and cooperation, as well as postoperative adverse events, were compared between groups.

RESULTS

More marked reductions in anxiety were observed among patients in the CAMA group, with corresponding reductions in SAS and SAI scores. During the operation, no change in the secretion of E, NE, or Cor group compared to the preoperative period was observed in the CAMA, which was markedly lower than that in the SA group. Heart rate, blood pressure, and respiratory rate were more stable intraoperatively in the CAMA group. In addition, the incidence of intraoperative pain and the number of additional doses of anesthesia required in the CAMA group were markedly lower than in the SA group. Accordingly, patients in the CAMA group were able to avoid eye movements and eyelid closing leading to greater cooperation with surgeons during surgery. Furthermore, marked reductions in intraoperative adverse effects were observed in the CAMA group, indicating greater overall safety.

CONCLUSION

Proparacaine SA combined with acupuncture as an analgesic provides improved analgesia with greater safety compared to surface anesthesia with proparacaine during geriatric cataract phacoemulsification.

Liquid biopsy for gastric cancer: Techniques, applications, and future directions

After the study of circulating tumor cells in blood through liquid biopsy (LB), this technique has evolved to encompass the analysis of multiple materials originating from the tumor, such as nucleic acids, extracellular vesicles, tumor-educated platelets, and other metabolites. Additionally, research has extended to include the examination of samples other than blood or plasma, such as saliva, gastric juice, urine, or stool. LB techniques are diverse, intricate, and variable. They must be highly sensitive, and pre-analytical, patient, and tumor-related factors significantly influence the detection threshold, diagnostic method selection, and potential results. Consequently, the implementation of LB in clinical practice still faces several challenges. The potential applications of LB range from early cancer detection to guiding targeted therapy or immunotherapy in both early and advanced cancer cases, monitoring treatment response, early identification of relapses, or assessing patient risk. On the other hand, gastric cancer (GC) is a disease often diagnosed at advanced stages. Despite recent advances in molecular understanding, the currently available treatment options have not substantially improved the prognosis for many of these patients. The application of LB in GC could be highly valuable as a non-invasive method for early diagnosis and for enhancing the management and outcomes of these patients. In this comprehensive review, from a pathologist's perspective, we provide an overview of the main options available in LB, delve into the fundamental principles of the most studied techniques, explore the potential utility of LB application in the context of GC, and address the obstacles that need to be overcome in the future to make this innovative technique a game-changer in cancer diagnosis and treatment within clinical practice.

Poorly controlled type II diabetes mellitus significantly enhances postoperative chemoresistance in patients with stage III colon cancer

BACKGROUND

Type II diabetes mellitus (T2DM) has been associated with increased risk of colon cancer (CC) and worse prognosis in patients with metastases. The effects of T2DM on postoperative chemoresistance rate (CRR) and long-term disease-free survival (DFS) and overall survival (OS) in patients with stage III CC who receive curative resection remain controversial.

AIM

To investigate whether T2DM or glycemic control is associated with worse postoperative survival outcomes in stage III CC.

METHODS

This retrospective cohort study included 278 patients aged 40-75 years who underwent surgery for stage III CC from 2018 to 2021. Based on preoperative T2DM history, the patients were categorized into non-DM (n = 160) and DM groups (n = 118). The latter was further divided into well-controlled (n = 73) and poorly controlled (n = 45) groups depending on the status of glycemic control. DFS, OS, and CRR were compared between the groups and Cox regression analysis was used to identify risk factors.

RESULTS

Patients in the DM and non-DM groups demonstrated similar DFS, OS, and CRR (DFS: 72.03% vs 78.75%, P = 0.178; OS: 81.36% vs 83.12%, P = 0.638; CRR: 14.41% vs 7.5%, P = 0.063). Poorly controlled DM was associated with a significantly worse prognosis and higher CRR than well-controlled DM (DFS: 62.22% vs 78.07%, P = 0.021; OS: 71.11% vs 87.67%, P = 0.011; CRR: 24.40% vs 8.22%, P = 0.015). High preoperative fasting plasma glucose [DFS: Hazard ratio (HR) = 2.684, P < 0.001; OS: HR = 2.105, P = 0.019; CRR: HR = 2.214, P = 0.005] and glycosylated hemoglobin levels (DFS: HR = 2.344, P = 0.006; OS: HR = 2.119, P = 0.021; CRR: HR = 2.449, P = 0.009) indicated significantly poor prognosis and high CRR, while T2DM history did not (DFS: HR = 1.178, P = 0.327; OS: HR = 0.933, P = 0.739; CRR: HR = 0.997, P = 0.581).

CONCLUSION

Increased preoperative fasting plasma glucose and glycosylated hemoglobin levels, but not T2DM history, were identified as risk factors associated with poor postoperative outcomes and high CRR in patients with stage III CC.

Unraveling the therapeutic potential of Calculus Bovis in liver cancer: A novel step for targeted cancer treatment

Hepatocellular carcinoma is one of the leading causes of cancer-related deaths globally, and effective treatments are urgently needed. The present study aimed to investigate the inhibitory effect of Calculus Bovis (CB) on liver cancer and the underlying mechanisms. CB inhibited M2 tumor-associated macrophage polarization and modulated the Wnt/β-catenin signaling pathway, thereby suppressing the proliferation of liver cancer cells. The inhibitory effect on liver cancer growth was confirmed by both in vivo and in vitro experiments (detailed by Huang et al). The present study provides a theoretical basis for the application of CB for the treatment of liver cancer, providing new avenues for liver cancer treatment.

Effect of perioperative enteral nutrition on immune and nutritional status of patients with gastric cancer after endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) uses high-frequency electrocution to gradually peel off cancerous tissue, causing major surgical trauma. Therefore, such patients' recovery path is long, and the method and timing of enteral nutritional supply need to be carefully determined. At present, no standardized intervention plan has been formed for perioperative nutritional support for gastric cancer patients.

AIM

To explore the effect of perioperative enteral nutrition on patients with early gastric cancer who are scheduled for ESD, as well as its impact on their postoperative immune and nutritional status.

METHODS

One hundred patients with early gastric cancer who were scheduled for ESD surgery at The Second People's Hospital of Lishui from October 2023 to October 2024 were selected as the study subjects. They were divided into either a control group or an experimental group according to the random number table method, with 50 patients in each group. Both groups received routine perioperative nutrition, while the experimental group additionally received perioperative enteral nutrition. The interventions were continued until the patients were discharged. The postoperative hospitalization duration, gastrointestinal function recovery (times to first bowel movement, first gas exhaust, and resumption of diet), prealbumin (PA), triglyceride (TG), albumin (ALB), inhibitory T cells (CD8⁺), nutritional risk screening (NRS) score, total protein (TP), helper T cells (CD4⁺), and gastrointestinal adverse reactions were compared between the two groups.

RESULTS

The experimental group had shorter postoperative hospital stays, and times to recovery of diet, first bowel movement, and first gas exhaustion compared to the control group (P < 0.05). At discharge, the experimental group had lower CD8⁺ T cells and higher CD4⁺ T cells than the control group (P < 0.05). On postoperative day 1, the experimental group had higher TP and lower ALB levels than the control group (P < 0.05). At discharge, the experimental group had higher hemoglobin, ALB, TP, and TG levels than the control group (P < 0.05). However, there was no significant difference in PA between the two groups on postoperative day 1 and at discharge (P > 0.05). There was also no significant difference in NRS scores between the two groups before surgery and at discharge (P > 0.05). The total incidence of gastrointestinal adverse reactions in the experimental group (12.00%) was lower than that of the control group (28.00%) (P < 0.05).

CONCLUSION

Perioperative enteral nutrition in patients with early gastric cancer undergoing ESD can effectively improve gastrointestinal function, enhance nutritional status, reduce the risk of gastrointestinal adverse reactions, and contribute to the recovery of immune function.

Efficacy of low-dose esketamine combined with propofol/etomidate mixture in painless gastroscopy anesthesia

BACKGROUND

Propofol/etomidate mixture is a common anesthetic for painless gastroscopy, but the anesthetic effect is not satisfactory. Esmketamine can achieve ideal anesthetic effect, and low-dose esmketamine has more reliable safety. However, the application of low-dose esmketamine combined with propofol/etomidate mixture in painless gastroscopy anesthesia has been less explored.

AIM

To evaluate the efficacy of low-dose esketamine combined with propofol/etomidate mixture in painless gastroscopy anesthesia.

METHODS

A prospective study was conducted on patients who were scheduled to undergo painless gastroscopy at the Hangzhou Traditional Chinese Medicine Hospital from June 2023 to June 2024. They were randomly divided into a control group and a combination group according to the random number table method. Both groups were given a mixture of propofol and etomidate, and the combination group was additionally given a low dose of esketamine. The anesthesia effects and incidence of adverse reactions (nausea and vomiting, hypotension, respiratory depression, and postoperative delirium) were compared between the two groups, as well as hemodynamic parameters [heart rate (HR) and mean arterial pressure (MAP)], respiratory parameters [respiratory rate (RR), arterial oxygen saturation] at the time of entering the room (T₁), starting sedation (T₂), inserting the gastroscope (T₃), withdrawing the gastroscope (T₄), and at the end of the operation (T₅), and cognitive function [mini-mental state examination (MMSE) score] at 15 min and 30 min after awakening.

RESULTS

The time to onset of anesthesia, time to recovery, and post-anesthesia care unit stay time in the combination group were shorter than those of the control group, and the number of additional anesthetic drugs and the total amount of additional anesthetic drugs used were less than those of the control group (P < 0.05). The interaction effect of HR, MAP, and RR at different time points between the two groups was statistically significant (P < 0.05). At T₁-T_2, the inter-group effects of the univariate repeated measures analysis of variance showed that there were no significant changes in HR, MAP, and RR in the two groups (P > 0.05). HR showed a trend of first increasing and then decreasing, while MAP showed a trend of first decreasing and then increasing at T₃-T₅ (P < 0.05). RR showed a decreasing trend at T₃-T₅ in the control group (P < 0.05). The inter-group effect of multivariate analysis of variance showed that the HR in the combination group was lower than that of the conventional group, while MAP and RR were higher at T₃-T₅ (P < 0.05). The results of univariate and multivariate analyses using the generalized estimating equation model showed that there were significant differences in HR, MAP, and RR among groups, times, and their interaction terms (P < 0.05). The MMSE scores of the combination group were higher than those of the control group at 15 minutes and 30 minutes after awakening (P < 0.05). The incidence of respiratory depression and delirium in the combination group was lower than that of the control group (P < 0.05).

CONCLUSION

The anesthetic effect of low-dose esketamine combined with propofol/etomidate mixture in painless gastroscopy anesthesia is good, which can maintain stable hemodynamics, reduce interference with breathing, accelerate postoperative cognitive function recovery, and reduce the incidence of respiratory depression and postoperative delirium.

Protective effects of amphetamine on gastric ulcerations induced by indomethacin in rats

AIM

To study the effects of amphetamine, an indirect-acting adrenomimetic compound on the indomethacin-induced gastric ulcerations in rats.

METHODS

Male Wistar-Bratislava rats were randomly divided into four groups: Group 1 (control), received an ulcerogenic dose of indomethacin (50 micromol/kg) and Groups 2, 3 and 4, treated with amphetamine (10, 25 and 50 micromol/kg). The drug was administered simultaneously with indomethacin and once again 4 h later. The animals were sacrificed 8 h after indomethacin treatment. The stomachs were opened and the incidence, the number of lesions and their severity were evaluated. The results were expressed as percentage and as mean+/-standard error (mean+/-SE).

RESULTS

The incidence of ulceration in the control group was 100%. Amphetamine, at doses of 10, 25 and 50 micromol/kg, lowered the incidence to 88.89%, 77.78% and 37.5% respectively. The protection ratio was positive: 24.14%, 55.17% and 80.6% respectively. The total number of ulcerations/rat was 12.44+/-3.69 in the control group. It decreased to 7.33+/-1.89, 5.33+/-2.38 and 2.25+/-1.97 under the effects of the above-mentioned doses of amphetamine.

CONCLUSION

Amphetamine affords a significant dose-dependent protection against the indomethacin-induced gastric ulcerations in rats. It is suggested that the adrenergic system is involved in the gastric mucosa protection.

Ursodeoxycholic acid combined with glucocorticoids for treatment of primary biliary cirrhosis with characteristics of autoimmune hepatitis

AIM

To observe the efficacy of ursodeoxycholic acid (UDCA) combined with glucocorticoids in the treatment of primary biliary cirrhosis (PBC) with characteristics of autoimmune hepatitis (AIH).

METHODS

Thirty-one patients with PBC with AIH characteristics were divided into two group: a UDCA alone group and a UDCA combined with glucocorticoid group. Blood biochemical indexes before and after treatment were retrospectively analyzed. Immunoglobulin indexes, liver pathological changes, and the status of response to treatment were also observed.

RESULTS

In both groups, the levels of alkaline phosphatase (ALP), γ-glutamyl transferase (GGT) and immunoglobulin M (IgM) decreased after therapy, and the improvement of ALP and IgM had statistical significance (P < 0.05). In the combination group, alanine transaminase, aspartate transaminase, GGT, ALP, globulin, and immunoglobulin obviously improved compared with baseline values. Biochemical responses showed no significant difference between the two groups, although the combination group had a higher response rate. In patients with different pathological stages of disease, ALP response rate was statistically significant (P < 0.05). The degree and extent of liver inflammation or fibrosis and bile duct damage significantly improved after treatment in the combination group.

CONCLUSION

For patients with PBC with AIH characteristics, a definitive diagnosis should be achieved as early as possible. UDCA plus glucocorticoid treatment is recommended to better control the progression of the disease.

Advances in treatment of HBV-related liver failure with nucleoside analogues

Hepatitis B virus (HBV) infection is a common cause of liver failure in China. The mortality of fulminant hepatitis B is more than 70%. Adoption of antiviral therapy or not on the basis of comprehensive treatment has become a hot topic of recent research of treatment of fulminant hepatitis B, which causes liver failure in a way different from other reasons. HBV replication plays a critical role in initiating the development of fulminant hepatitis B. Reducing viral load to alleviate excessive immune response by antiviral therapy represents a new idea for the treatment of fulminant hepatitis B. The advent of nucleoside analogues makes it possible to conduct antiviral therapy against fulminant hepatitis B. This article summarizes recent advances in treatment of HBV-related liver failure with nucleoside analogues.

Paneth cells and intestinal health

Paneth cells (PC) are a group of secretory cells derived from intestinal stem cells (ISC) and colonized in the bottom of the small intestinal crypt. As an important "guardian" of intestinal health, PC can not only secrete a variety of antibacterial peptides and cytokines to regulate intestinal homeostasis and participate in immune responses, but also release growth factors to support the stem cell niche and regulate their proliferation and differentiation. Of particular concern, as a static stem cell pool, PC can acquire a stem cell-like transcriptome after the injury of intestinal tissue so as to promote regeneration and repair the damaged intestinal tissue. Particularly, PC are closely related to a number of diseases that affect intestinal health, such as inflammatory bowel disease (IBD) and colorectal cancer (CRC). The research of biological functions of PC may provide ideas for the treatment of these diseases. In summary, the role of PC in maintaining intestinal health should not be underestimated.

Treatment of chronic hepatitis B patients harboring YMDD variants

AIM: To evaluate the efficacy and safety of adefovir dipivoxil alone or in combination with lamivudine or entecavir in the treatment of chronic hepatitis B (CHB) patients harboring YMDD variants.

METHODS: One hundred and twenty CHB patients with YMDD variants were randomly divided into four groups: patients receiving adefovir dipivoxil alone for 96 weeks (Group A), those receiving adefovir dipivoxil in combination with lamivudine during the first 12 weeks and adefovir dipivoxil alone for the following 84 weeks (Group B), those receiving adefovir dipivoxil in combination with lamivudine for 96 weeks (Group C), and those receiving entecavir alone for 96 weeks (Group D). Before treatment and at weeks 0, 4, 12, 24, 48, 72 and 96 after treatment, liver function, hepatitis B virus (HBV)-DNA level, HBV serological markers, serum phosphorus and renal function were determined in all patients. HBV YMDD mutation was detected in HBV DNA-positive patients. Sequencing of HBV P gene was performed in patients with a non-virological response or virological breakthrough.

RESULTS: After 96 weeks of treatment, no significant differences were noted in serum alanine aminotransferase (ALT) level and hepatitis B e-antigen (HbeAg) seroconversion rate among the four groups (all P > 0.05). However, significant differences were observed in ALT normalization rate and the percentage of patients with undetectable HBV DNA between the Group A and Group C (χ² = 7.500 and 6.648, respectively; both P < 0.05). The frequencies of drug resistant genotypes in the four groups were16.7% (5/30), 13.3% (4/30), 0 and 13.3% (4/30), respectively. Severe hepatitis occurred in one patient in the Group A.

CONCLUSION: Adefovir dipivoxil in combination with LAM is safe and effective in the treatment of chronic hepatitis B patients with YMDD variants.

Effect of Traditional Chinese Medicine Xiangganlong combined with Lamivudine in treatment of active hepatitis: An analysis of 90 cases

AIM: To investigate the long term effect of Traditional Chinese Medicine Xiangganlong combined with Lamivudine in the treatment of active hepatitis and cirrhosis.

METHODS: The randomly selected 90 patients with active hepatitis and cirrhosis were divided into treatment group and control group. The patients in the former were treated with Xiangganlong combined with Lamivudine, the patients in the control group were treated with general treatment according to the symptoms. Six to sixty-seven months after treatment, the serum virus level, liver function, complications, the occurrence rate of hepatocellular carcinoma, and the mortality rate were analyzed.

RESULTS: The negative rates of hepatitis B virus DNA in the patients of treatment group and control group were 61.4% (27/44) and 6.5% (3/46), respectively, and there was significant difference between them (P = 0.000 1). The negative rate of HBeAg was also markedly higher in the patients of treatment group than that in the controls [33.3% (11/33) vs 6.7% (2/30), P = 0.032 1]. The variation rates of YMDD were 11.4%, 22.7%, 34.1%, 38.6% after 12, 24, 36, 37-67 mo of combined Lamivudine treatment, respectively. In the patients with no YMDD variation, the total bilirubin (TBiL) and Child-pugh score were significantly declined, while the level of albumin (A) was increased as compared with that in the controls (17.90±1.01 μmol/L vs 62.57±52.23 μmol/L, P <0.01; 5.18±1.40 vs 7.50±3.16, P <0.01; 42.32±6.39 g/L vs 38.35±7.27 g/L, P <0.01). The occurrence rate of complications was 11.4% and 45.6% (P = 0.007) in the treatment and control group, respectively, while the occurrence rate of hepatocellular carcinoma was not significantly different between those two groups (P = 0.299 8). The mortality was 9.1% and 30.4% (P = 0.037 7) in the treatment and control group, respectively.

CONCLUSION: The Traditional Chinese Medicine Xiangganlong combined with Lamivudine can impress the proliferation of HBV, decrease the variation rates of YMDD, improve the hepatic function, reduce the occurrence of the complications and mortality.

MRI features of regenerative and dysplastic nodules in cirrhotic liver

AIM: To study MR features of the regenerative nodule (RN) and dysplastic nodule (DN) in the cirrhotic liver.

METHODS: MRI was performed in 26 cases of suspected cirrhotic liver with RN and DN. Additional enhanced MRI with administration of Gd-DTPA on T1WI was performed in 18 of 26 cases. Meanwhile in 10 of 18 both Gd-DTPA and SPIO (Feridex) enhancement were underwent one day apart. All patients were confirmed by aspiration biopsy or histopathology. MRI was compared to the pathological findings.

RESULTS: In 26 cases, there were 12 cases of regenerative nodules measuring 0.3-1cm in size, and 14 dysplastic nodules including 8 nodules measuring ≥1 cm and <3 cm in size, and 6 nodules measuring ≥3 cm. Their MR appearances were as followings: nodules with <1 cm in size showed isointensity on T₁WI and hypointensity on T₂WI, of which the intensity was as isointense as the surrounding hepatic parenchyma on enhanced MRI with administration of Gd-DTPA or SPIO. In 8 cases with nodules measuring 1-3 cm in size, 5 cases appeared hyperintense on T1WI and hypointense on T₂WI as well as the enhancement as that of nodules with <1 cm in size; the other 3 cases appeared hypointense on T₁WI and hyperintense on T₂WI, and were enhanced after administration of Gd-DTPA but hyperintense on SPIO enhancing MRI, which indicated malignant transformation of dysplastic nodule into hepatocellular carcinoma (HCC) arising from hepatic nodule on histopathology. In 6 cases of nodules measuring >3 cm in size, 2 cases appeared hyperintense compared to the surrounding hepatic parenchyma on T₁, T₂WI and enhanced MRI, one of which was documented "nodule within a nodule" on T₂WI. The 2 cases were demonstrated well-differentiated HCC. The other 4 cases showed hyperintense on T1WI, and hypointense on T₂WI and enhanced MRI. Sometimes, normal vessels were seen to pass through the surface of macroregenerative nodule. Additionally, RN and DN had the same pattern of the time-signal intensity course as the normal surrounding hepatic parenchyma, but malignant transformation of DN appeared fast wash-in and wash-out.

CONCLUSION: RN of cirrhosis has features on MRI that usually allow distinction from HCC but not always from DN. A helpful distinction between HCC and DN is that the latter is almost never hyperintense on T₂WI. Additionally, the followings indicate malignant transformation of DN when DN appears a ring like enhancement after injection of Gd-DTPA, and fast wash-in and wash-out as well as hyperintensity on SPIO enhanced MRI.

Liver stiffness in pregnant women with intrahepatic cholestasis of pregnancy: A case control study

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a rare but severe complication for both the mother and the unborn child. The diagnosis is primarily based on elevated serum levels of bile acids. In a large ICP cohort, we here study in detail liver stiffness (LS) using transient elastography (TE), now widely used to non-invasively screen for liver cirrhosis within minutes.

AIM

To specifically explore LS in a large cohort of women with ICP compared to a control group with uncomplicated pregnancy.

METHODS

LS and hepatic steatosis marker controlled attenuation parameter (CAP) were measured in 100 pregnant women with ICP using TE (Fibroscan, Echosens, Paris, France) between 2010 and 2020. In 17 cases, LS could be measured postpartum. 450 women before and 38 women after delivery with uncomplicated pregnancy served as control group. Routine laboratory, levels of bile acids and apoptosis marker caspase-cleaved cytokeratin 18 fragment (M30) were also measured.

RESULTS

Women with ICP had significantly elevated transaminases but normal gamma-glutamyl transferase (GGT). Mean LS was significantly increased at 7.3 ± 3.0 kPa compared to the control group at 6.2 ± 2.3 kPa (P < 0.0001). Postpartum LS decreased significantly in both groups but was still higher in ICP (5.8 ± 1.7 kPa vs 4.2 ± 0.9 kPa, P < 0.0001), respectively. In ICP, LS was highly significantly correlated with levels of bile acids and M30 but not transaminases. No correlation was seen with GGT that even increased significantly after delivery in the ICP group. Bile acids were mostly correlated with the liver apoptosis marker M30, LS and levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin. In multivariate analysis, LS remained the sole parameter that was independently associated with elevated bile acids.

CONCLUSION

In conclusion, LS is significantly elevated in ICP which is most likely due to toxic bile acid accumulation and hepatocyte apoptosis. In association with conventional laboratory markers, LS provides additional non-invasive information to rapidly identify women at risk for ICP.

Multifunctional role of oral bacteria in the progression of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of liver disorders of varying severity, ultimately leading to fibrosis. This spectrum primarily consists of NAFL and non-alcoholic steatohepatitis. The pathogenesis of NAFLD is closely associated with disturbances in the gut microbiota and impairment of the intestinal barrier. Non-gut commensal flora, particularly bacteria, play a pivotal role in the progression of NAFLD. Notably, Porphyromonas gingivalis, a principal bacterium involved in periodontitis, is known to facilitate lipid accumulation, augment immune responses, and induce insulin resistance, thereby exacerbating fibrosis in cases of periodontitis-associated NAFLD. The influence of oral microbiota on NAFLD via the "oral-gut-liver" axis is gaining recognition, offering a novel perspective for NAFLD management through microbial imbalance correction. This review endeavors to encapsulate the intricate roles of oral bacteria in NAFLD and explore underlying mechanisms, emphasizing microbial control strategies as a viable therapeutic avenue for NAFLD.

Sarcopenia in cirrhotic patients: Does frailty matter while waiting for a liver transplant?

Sarcopenia reflects patient frailty and should be routinely assessed due to its high prevalence in cirrhotic patients awaiting liver transplants. Pre-transplant nutritional optimization should be tailored for patients with a definitive diagnosis of sarcopenia, therefore improving functional status at transplant and reducing post-transplant mortality. Hepatologists and transplant surgeons should have raised awareness regarding sarcopenia and the reflected frailty that hinder posttransplant outcomes. The policymakers should also take into account when modifying the organ allocation model that sarcopenia or frailty might become a decisive factor in allocating organs for cirrhotic patients, in order to ensure post-transplant survival and quality of life.

Gut microbiome composition in patients with liver cirrhosis with and without hepatic encephalopathy: A systematic review and meta-analysis

BACKGROUND

The gut microbiome is associated with hepatic encephalopathy (HE), but research results on the gut microbiome characteristics of patients with liver cirrhosis with and without HE are inconsistent.

AIM

To study the gut microbiota characteristics of patients with liver cirrhosis with and without HE.

METHODS

We searched the PubMed, Web of Science, EMBASE, and Cochrane databases using two keywords, HE, and gut microbiome. According to the inclusion and exclusion criteria, suitable literature was screened to extract data on the diversity and composition of the fecal microbiota in patients with liver cirrhosis with and without HE. The data were analyzed using RevMan and STATA.

RESULTS

Seventeen studies were included: (1) A meta-analysis of 7 studies revealed that the Shannon index in liver cirrhosis patients with HE was significantly lower than that in patients without HE [-0.20, 95% confidence interval (CI): -0.28 to -0.13, I2 = 20%]; (2) The relative abundances of Lachnospiraceae (-2.73, 95%CI: -4.58 to -0.87, I2 = 38%) and Ruminococcaceae (-2.93, 95%CI: -4.29 to -1.56, I2 = 0%) in liver cirrhosis patients with HE was significantly lower than those in patients without HE; (3) In patients with HE, Enterococcus, Proteobacteria, Enterococcaceae, and Enterobacteriaceae proportions increased, but Ruminococcaceae, Lachnospiraceae, Prevotellaceae, and Bacteroidetes proportions decreased; (4) Differences in the fecal metabolome between liver cirrhosis patients with and without HE were detected; and (5) Differential gut microbiomes may serve as diagnostic and prognostic tools.

CONCLUSION

The gut microbiomes of patients with liver cirrhosis with and without HE differ. Some gut microbiomes may distinguish liver cirrhosis patients with or without HE and determine patient prognosis.

Bariatric surgery and diabetes: Current challenges and perspectives

Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.

Early prediction of anastomotic leakage after rectal cancer surgery: Onodera prognostic nutritional index combined with inflammation-related biomarkers

BACKGROUND

Anastomotic leakage (AL) is a serious complication following rectal cancer surgery and is associated with increased recurrence, mortality, extended hospital stays, and delayed chemotherapy. The Onodera prognostic nutritional index (OPNI) and inflammation-related biomarkers, such as the neutrophil-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), have been studied in the context of cancer prognosis, but their combined efficacy in predicting AL remains unclear.

AIM

To investigate the relationships between AL and these markers and developed a predictive model for AL.

METHODS

A retrospective cohort study analyzed the outcomes of 434 patients who had undergone surgery for rectal cancer at a tertiary cancer center from 2016 to 2023. The patients were divided into two groups on the basis of the occurrence of AL: One group consisted of patients who experienced AL (n = 49), and the other group did not (n = 385). The investigation applied logistic regression to develop a risk prediction model utilizing clinical, pathological, and laboratory data. The efficacy of this model was then evaluated through receiver operating characteristic curve analysis.

RESULTS

In the present study, 11.28% of the participants (49 out of 434 participants) suffered from AL. Multivariate analysis revealed that preoperative levels of the OPNI, NLR, and PLR emerged as independent risk factors for AL, with odds ratios of 0.705 (95%CI: 0.641-0.775, P = 0.012), 1.628 (95%CI: 1.221-2.172, P = 0.024), and 0.994 (95%CI: 0.989-0.999, P = 0.031), respectively. These findings suggest that these biomarkers could effectively predict AL risk. Furthermore, the proposed predictive model has superior discriminative ability, as demonstrated by an area under the curve of 0.910, a sensitivity of 0.898, and a specificity of 0.826, reflecting its high level of accuracy.

CONCLUSION

The risk of AL in rectal cancer surgery patients can be effectively predicted by assessing the preoperative levels of serum nutritional biomarkers and inflammatory indicators, emphasizing their importance in the preoperative evaluation process.