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Esophageal squamous cell carcinoma (ESCC) is the most common histological subtype of esophageal cancer worldwide. Patients with ESCC display an altered esophageal microbiota compared with healthy individuals; however, little is known about the gut microbiota in ESCC.Here, we characterized the fecal microbiota of 15 ESCC patients and 16 healthy control subjects using 16S rRNA gene sequencing.After controlling for potential confounders, significant alterations in both taxonomic and functional composition of the gut microbiota in ESCC patients were observed. By contrast, alpha diversity of the gut microbiota did not significantly differ between the cases and controls. We observed an enrichment of potentially pro-inflammatory and/or carcinogenic bacteria, such as Butyricimonas, Veillonella, and Streptococcus, and a depletion of butyrate-producing and/or potentially anti-inflammatory bacteria, such as Butyricicoccus, Lachnospiraceae NK4A136 group, and Eubacterium eligens group, in the gut microbiota of ESCC patients. The log-ratios of Streptococcus to Butyricicoccus and Streptococcus to Lachnospiraceae NK4A136 group of the gut microbiota were identified as potential diagnostic biomarkers for ESCC, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.863 (95% confidence interval: 0.707-1.000) and 0.825 (0.673-0.977), respectively. The diagnostic performance of both microbial biomarkers was validated in another ESCC cohort.This pilot study has revealed an altered gut microbiota in ESCC patients and has paved the way for large-scale prospective cohort studies to examine the causative relationship between ESCC and gut dysbiosis.

The aim of the study was to compare the clinical symptoms between Billroth II (B-II) and Roux-en-Y (R-Y) reconstruction after distal subtotal gastrectomy (DG) for gastric cancer.Surgery is the mainstay of curative treatment for gastric cancer. The technique for reconstruction after DG remains controversial. Both B-II and R-Y are popular methods.This is a prospective multicenter randomized controlled trial. From October 2008 to October 2014, 162 patients who underwent DG were randomly allocated to B-II (n = 81) and R-Y (n = 81) groups. The primary endpoint is Gastrointestinal (GI) Symptoms Score 1 year after surgery. We also compared the nutritional status, extent of gastritis on endoscopy, and quality of life after surgery between the 2 procedures at 1 year.Operative time was significantly shorter for B-II than for R-Y [mean difference 21.5 minutes, 95% confidence interval (95% CI) 3.8-39.3, P = 0.019]. The B-II and R-Y groups had a peri-operative morbidity of 28.4% and 33.8%, respectively (P = 0.500) and a 30-day mortality of 2.5% and 1.2%, respectively (P = 0.500). GI symptoms score did not differ between R-Y versus B-II reconstruction (mean difference -0.45, 95% CI -1.21 to 0.31, P = 0.232). R-Y resulted in a lower median endoscopic grade for gastritis versus B-II (mean difference -1.32, 95% CI -1.67 to -0.98, P0.001). We noted no difference in nutritional status (R-Y versus B-II mean difference -0.31, 95% CI -3.27 to 2.65, P = 0.837) and quality of life at 1 year between the 2 groups too.Although BII is associated with a higher incidence of heartburn symptom and higher median endoscopic grade for gastritis, BII and RY are similar in terms of overall GI symptom score and nutritional status at 1 year after distal gastrectomy.

Causes of Mortality in Patients With Peptic Ulcer Bleeding: A Prospective Cohort Study of 10,428 Cases

Background & Aims Despite advances in management of patients with bleeding peptic ulcers, mortality is still 10%. This study aimed to identify predictive factors and to develop a prediction model for mortality among patients with bleeding peptic ulcers. Methods Consecutive patients with endoscopic stigmata of active bleeding, visible vessels, or adherent clots were recruited, and risk factors for mortality were identified in this deprivation cohort by using multiple stepwise logistic regression. A prediction model was then built on the basis of these factors and validated in the evaluation cohort. Results From 1993 to 2003, 3220 patients with bleeding peptic ulcers were treated. Two hundred eighty-four of the patients developed rebleeding (8.8%); emergency surgery was performed on 47 of these patients, whereas others were managed with endoscopic retreatment. Two hundred twenty-nine of these sustained in-hospital death (7.1%). In patients older than 70 years, presence of comorbidity, more than 1 listed comorbidity, hematemesis on presentation, systolic blood pressure below 100 mm Hg, in-hospital bleeding, rebleeding, and need for surgery were significant predictors for mortality. Helicobacter pylori –related ulcers had lower risk of mortality. The receiver operating characteristic curve comparing the prediction of mortality with actual mortality showed an area under the curve of 0.842. From 2004 to 2006, data were collected prospectively from a second cohort of patients with bleeding peptic ulcers, and mortality was predicted by using the model developed. The receiver operating characteristic curve showed an area under the curve of 0.729. Conclusions Among patients with bleeding peptic ulcers after endoscopic hemostasis, advanced age, presence of listed comorbidity, multiple comorbidities, hypovolemic shock, in-hospital bleeding, rebleeding, and need for surgery successfully predicted in-hospital mortality.

Background The impact of intragastric balloon (IGB) on obesity-related illnesses and quality of life (QOL) has not been previously investigated. Method One hundred and nineteen consecutive obese patients (86 females; mean age 37.8; mean body weight (BW) 103.7±24.1 kg; mean BMI 38.4±8.0 kg/m 2 ) who underwent IGB were evaluated for improvement on obesity-related illnesses and QOL after weight reduction in a multidisciplinary university referral center. Bioenterics Intragastric balloon (BIB®) system was employed in the study. Results Mean treatment period was 169.9±34.8 days. Mean BW, BMI, and excess body weight loss were 12.4±6.9 kg, 4.6±2.7 kg/m 2 , and 45.1±35.3%. Mean waist circumference and biceps fold and triceps fold loss were 10.5±8.3, 9.8± 8.5, and 8.7±7.4 cm respectively. Metabolic syndrome was decreased from 42.9% to 15.1% after IGB (p

Background EUS may be used to reduce the need of diagnostic ERCP. Objective Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. Design A randomized study. Setting A university medical unit. Patients Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. Interventions In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. Main Outcome Measurements The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. Results Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. Conclusions In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.

Aim: There are some discrepancies as to the prognostic value of perigastric lymph node (LN) metastasis in the survival of squamous oesophageal carcinoma. The present study aimed to compare survival following standard oesophagectomy in the treatment of squamous oesophageal carcinoma with or without perigastric abdominal LN metastasis. Methods: From 1998 to 2003, 17 patients with squamous cell carcinoma of the mid or lower oesophagus who had abdominal LN metastasis upon pathological examination underwent Ivor Lewis oesophagectomy. They did not receive further adjuvant therapy. The clinical outcomes of this cohort were compared to a control of 34 patients of similar age, gender and T staging who had no perigastric nodal diseases upon oesophagectomy. Results: There was no significant difference between the two groups in terms of the demographics, tumour size, differentiation of the tumour, duration of operation, volume of blood loss, and the type of oesophagectomy. The cumulative 3-year survival rate was similar between those with abdominal LN metastasis or those without abdominal LN metastasis (52.9% vs 47.1%; log–rank test P = 0.61).There was also no significant difference in the rates of recurrence between the two groups (58.8% vs 58.8%; P = 0.1). Conclusions: Perigastric LN metastasis over the lesser curvature, left gastric artery and pericardial regions does not affect the survival of patients with squamous cell carcinoma of the oesophagus treated by two-field oesophagectomy.

Laparoscopic sleeve gastrectomy (LSG) is an effective stand-alone bariatric procedure with favorable short-term results on weight reduction and comorbidity resolution. This study aims to evaluate the long-term results of LSG to see if weight reduction and diabetic improvement are sustainable.We conducted a prospective observational study on patients receiving LSG as an index stand-alone bariatric operation in our unit.Between 2006 and 2014, there were 140 patients (91 females) aged 37.9 ± 10.5 years with a body mass index of 41.0 ± 7.0 kg/m(2). At 1-year (n = 123), 2-year (n = 99), 3-year (n = 77), 4-year (n = 52), and 5-year (n = 44) follow-ups, the mean percentages of excess weight loss (%EWL) were 70.5, 65.2, 60.2, 53.2, and 57.2%, respectively, while the corresponding proportions with failed weight loss (%EWL30%) were 7.3, 9.1, 13.0, 25.0, and 22.7%. Weight regain (25% rebound in %EWL) was evident with time as 0, 1.0, 11.6, 19.2, and 29.5% in the first 5-year follow-ups. In 65 patients with type 2 diabetes mellitus, remission (complete and partial) was achieved in 34.5% at 1-year, 52.7% at 3-year, and 70.6% at 5-year follow-ups. Proportions of patients having optimal glycemic control (HbA1c7%) increased significantly from 26.2% preoperatively to 80.9% at the first year and maintained at 78.6% at the fifth year (P 0.001).LSG was effective in achieving substantial weight reduction and improved diabetic control for morbidly obese patients. Although weight regain was possible with time, majority of patients could maintain sustainable weight loss, diabetes remission, and glycemic improvement in the long run.

AIM: To evaluate the economic impact of celecoxib therapy vs. diclofenac plus omeprazole therapy for the treatment of arthritis in Chinese patients with a high risk of bleeding, from the perspective of a public health organization in Hong Kong. METHODS: The medical records of 287 Chinese arthritic patients with a history of bleeding ulcers who had previously participated in a randomised study of celecoxib 200 mg twice daily and extended-release diclofenac 75 mg twice daily plus 20 mg of omeprazole daily for 6 months were reviewed. RESULTS: Compared to the diclofenac plus omeprazole group, the average total direct cost per patient in the celecoxib group showed a significant reduction of 11%, from HK 10,915 (range HK dollars 10,915-57,899) to HK dollars 9714 (range HK dollars 9714-89,770) (P

background There has been an outbreak of the severe acute respiratory syndrome (SARS) worldwide. We report the clinical, laboratory, and radiologic features of 138 cases of suspected SARS during a hospital outbreak in Hong Kong. methods From March 11 to 25, 2003, all patients with suspected SARS after exposure to an index patient or ward were admitted to the isolation wards of the Prince of Wales Hospital. Their demographic, clinical, laboratory, and radiologic characteristics were analyzed. Clinical end points included the need for intensive care and death. Univariate and multivariate analyses were performed. results There were 66 male patients and 72 female patients in this cohort, 69 of whom were health care workers. The most common symptoms included fever (in 100 percent of the patients); chills, rigors, or both (73.2 percent); and myalgia (60.9 percent). Cough and headache were also reported in more than 50 percent of the patients. Other common findings were lymphopenia (in 69.6 percent), thrombocytopenia (44.8 percent), and elevated lactate dehydrogenase and creatine kinase levels (71.0 percent and 32.1 percent, respectively). Peripheral air-space consolidation was commonly observed on thoracic computed tomographic scanning. A total of 32 patients (23.2 percent) were admitted to the intensive care unit; 5 patients died, all of whom had coexisting conditions. In a multivariate analysis, the independent predictors of an adverse outcome were advanced age (odds ratio per decade of life, 1.80; 95 percent confidence interval, 1.16 to 2.81; P=0.009), a high peak lactate dehydrogenase level (odds ratio per 100 U per liter, 2.09; 95 percent confidence interval, 1.28 to 3.42; P=0.003), and an absolute neutrophil count that exceeded the upper limit of the normal range on presentation (odds ratio, 1.60; 95 percent confidence interval, 1.03 to 2.50; P=0.04). conclusions SARS is a serious respiratory illness that led to significant morbidity and mortality in our cohort.

Summary Background Whether Helicobacter pylori increases the risk of ulcers in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) is controversial. We hypothesised that eradication of H pylori infection would reduce the risk of ulcers for patients starting long-term NSAID treatment. Methods Patients were enrolled if they were NSAID naive, had a positive urea breath test, had dyspepsia or an ulcer history, and required long-term NSAID treatment. They were randomly assigned omeprazole triple therapy (eradication group) or omeprazole with placebo antibiotics (placebo group) for 1 week. All patients were given diclofenac slow release 100 mg daily for 6 months from randomisation. Endoscopy was done at 6 months or if severe dyspepsia or gastrointestinal bleeding occurred. The primary endpoint was the probability of ulcers within 6 months. Analyses were by intention to treat. Findings Of 210 arthritis patients screened, 128 (61%) were positive for H pylori . 102 patients were enrolled, and 100 were included in the intention-to-treat analysis. H pylori was eradicated in 90% of the eradication group and 6% of the placebo group. Five of 51 eradication-group patients and 15 of 49 placebo-group patients had ulcers. The 6-month probability of ulcers was 12·1% (95% CI 3·1–21·1) in the eradication group and 34·4% (21·1–47·7) in the placebo group (p=0·0085). The corresponding 6-month probabilities of complicated ulcers were 4·2% (1·3–9·7) and 27·1% (14·7–39·5; p=0·0026). Interpretation Screening and treatment for H pylori infection significantly reduces the risk of ulcers for patients starting long-term NSAID treatment.

Background: One-week triple regimens have been shown to be effective for the treatment of Helicobacter pylori-related peptic ulcer disease. Aim: To conduct an economic analysis of four triple regimens for the treatment of H. pylori-related peptic ulcer disease from the perspective of a public health organization in Hong Kong. Methods: Records of 200 patients with H. pylori-related peptic ulcer disease, who had previously participated in a randomized comparison of ranitidine bismuth citrate (RBC) with amoxicillin and clarithromycin (RAC), omeprazole with amoxicillin and clarithromycin (OAC), RBC with metronidazole and tetracycline (RMT), or, colloidal bismuth subcitrate with metronidazole and tetracycline (BMT) in either in-patient or out-patient setting were reviewed. Results: Fifty patients were excluded because of incomplete documentation or lack of peptic ulcer. In the out-patient group (n=72), the median direct costs of the RAC group (HK $ 5094) were lower those of the BMT (HK $ 5400), RMT (HK $ 5394), or OAC (HK $ 5440) groups, but the difference was significant only between the RAC and BMT groups (P

After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients.We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy.We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13).After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.

Background: Bleeding gastric varices is a highly fatal condition. Recurrent bleeding after hemostasis achieved by endoscopic methods is common, and obliteration of gastric varices is difficult to assess. Our aim was to investigate the use of endosonography (EUS) in monitoring cyanoacrylate injection to obliterate gastric varices. Methods: Patients who presented with bleeding gastric varices were treated with bolus injection(s) of cyanoacrylate (0.5 mL cyanoacrylate mixed with 0.7 mL Lipiodol) until bleeding was controlled; 47 patients received "on-demand" injection only in response to recurrent bleeding (on-demand group). Another group of 54 patients underwent biweekly EUS followed by repeated injection of cyanoacrylate (repeated-injection group) until all gastric varices were obliterated. The primary outcome was recurrent bleeding–free interval and survival rate. Results: The two groups of patients were comparable demographically. Although the rates of early (≤48 hour) bleeding recurrence were similar with repeated or on-demand injection (7.4% versus 12.8%, p = 0.5), late recurrence of bleeding (>48 hour) was significantly reduced in the repeated-injection group (18.5% versus 44.7%, p = 0.0053, odds ratio 0.28 (95% CI [0.12, 0.69]). Cumulative probability of recurrent bleeding–free interval was higher in the repeated-injection than the on-demand group (log-rank test, p = 0.0053). There was a numeric trend toward improved survival in the repeated-injection group. Conclusion: Gastric varices obliteration with cyanoacrylate under EUS monitoring reduces recurrent bleeding and may improve survival. (Gastrointest Endosc 2000;52:168-74.)

The long-term results of omental patch repair for perforated duodenal ulcer are unsatisfactory; a high incidence of ulcer recurrence has been repeatedly reported. 1–4 Some advocate immediate acid-reduction procedures in addition to repair of the ulcer as a preventive measure against subsequent ulcer relapse. 5,6 Immediate definitive surgery in selected patients is safe, without increasing the rate of perioperative complications or death. 7 However, with recent advances in antiulcer medical therapy, fewer surgeons have acquired sufficient expertise in performing the definitive operation. Moreover, because perforated peptic ulcer isoften an “out of hours” emergency, a simpler life-saving procedure such as omental patch repair is an attractive option in many centers. The recent rediscovery of Helicobacter pylori has revolutionized the therapeutic approach to peptic ulcer disease. Eradication of H. pylori heals most uncomplicated peptic ulcers and prevents relapse. 8–10 In the case of bleeding peptic ulcers, a short course of antibiotics eradicating H. pylori is as efficacious as maintenance acid-reduction medication in preventing recurrent ulcer hemorrhage. 11 Both the National Institute of Health Consensus Meeting and the Maastricht Meeting of the European Helicobacter pylori Study Group have recommended eradication of H. pylori as the standard treatment for uncomplicated and bleeding peptic ulcers. 12,13 However, the association between H. pylori and perforated duodenal ulcer is less well defined. The reported infection rates range widely, from 47% by serologic testing 14 to more than 80% in two recent biopsy-based studies. 15,16 Whether there is a causal relation between the bacterium and duodenal ulcer perforation is controversial. We therefore performed a prospective randomized trial to determine whether eradication of H. pylori could lead to sustained ulcer remission in patients who underwent only simple repair for duodenal ulcer perforation.

Background: Proton pump inhibitors have been widely used in combination with amoxycillin, clarithromycin or metronidazole for the treatment of Helicobacter pylori infection. Aim: To study the effects of 1-week ranitidine bismuth citrate (RBC)-based triple therapy in the treatment of H. pylori-related duodenal ulcers. Method: Patients with duodenal ulcers and H. pylori infection were prospectively randomized to receive either RBC with amoxycillin and clarithromycin for 1 week (RAC), or omeprazole with amoxycillin and clarithromycin for 1 week (OAC). No additional ulcer healing drug was used after the 1-week medication. Patients were assessed for H. pylori eradication, ulcer healing and side-effects after receiving the therapies. Results: One hundred consecutive patients were recruited to this study, with 50 patients randomized to each treatment group. In the intention-to-treat analysis, duodenal ulcers were completely healed in 45 (90%) patients in the RAC group and 43 (89.6%) in the OAC group (P = 1.0). H. pylori eradication was confirmed in 47 (94%) in the RAC group and 42 (87.5%) in the OAC group (P = 0.31). There was no significant difference in the severity of side-effects experienced by the two treatment groups. Conclusion: One-week RBC-based triple therapy is an effective treatment for H. pylori-related duodenal ulcers. The therapeutic effects are comparable to a 1-week course of proton pump inhibitor-based triple therapy.

Background and Study Aims: Stigmata of hemorrhage in bleeding peptic ulcers have prognostic characteristics. In the present study, the evolution of these stigmata was studied prospectively using daily endoscopic examinations. Patients and Methods: From January 1989 to October 1989, 778 consecutive patients with bleeding peptic ulcers underwent endoscopy within 24 hours of admission. The bleeding peptic ulcers were assigned by three endoscopists to five categories, those with: a) active bleeding, b) a nonbleeding visible vessel, c) adherent clot, d) dot, or e) a clean base. Actively bleeding ulcers were treated by epinephrine injection. Ulcers with nonbleeding visible vessels, adherent clots, or dots were left untreated. Daily endoscopic examinations were carried out for three subsequent days, or until the ulcer base became clean. Results: On day 0, there were 56 actively bleeding ulcers (7 %), 62 ulcers with visible vessels (8 %), 104 with adherent clots (13 %), 182 with flat dots (23 %), and 374 with a white base (48 %). On the subsequent three days, 24 of 62 ulcers with visible vessels (39 %), 30 of 104 with adherent clots (29 %), 24 of 182 with dots (13 %), and 19 of 374 with a clean base (5 %) on day 0 re-bled endoscopically or clinically, or both. The overall rebleeding risk was 9.9 %, 4.9 %, and 2.7 % on days 1, 2, and 3, respectively. Conclusions: Stigmata of hemorrhage in bleeding peptic ulcers are predictive of rebleeding. They represent intermediate phases in the evolution of bleeding vessels into clean-based ulcers. The associated rebleeding risk diminishes as the vessel disappears from the ulcer base.

Background: Rebleeding following epinephrine injection of bleeding peptic ulcers occurs in 10% to 20% of all cases. The addition of a sclerosant has the theoretical advantage of inducing vessel thrombosis and permanent hemostasis. Methods: A prospective randomized controlled trial was conducted to compare injections with epinephrine alone or epinephrine plus absolute alcohol in patients with actively bleeding ulcers at endoscopy. Repeat endoscopy was performed 24 hours later; treatment was repeated in the presence of endoscopic signs of rebleeding. Surgery was performed when arterial bleeding could not be controlled endoscopically, clinical rebleeding with hematemesis or shock occurred, or the transfusion total exceeded 8 units. Results: One hundred sixty patients were enrolled (epinephrine alone, 81; epinephrine and absolute alcohol, 79). They were matched in age, sex, location of ulcers, hemoglobin on admission, shock, and severity of bleeding. Initial hemostasis was comparable: 79 of 81 with epinephrine alone (97.5%) versus 75 of 79 with epinephrine and absolute alcohol (94.9%). No difference was observed between the two with respect to either rebleeding (9 vs 6), need for emergency operation (12 vs 9), transfusion requirement (median, three units vs two units), hospital stay (median, 5 days vs 4 days), mortality (4 vs 7) and ulcer healing at 4 weeks (50 vs 46). Conclusions: The additional injection of absolute alcohol after endoscopic epinephrine injection confers no advantage. (Gastrointest Endosc 1996;43:591-5.)

Up to a third of patients have early rebleeding from oesophageal varices after endoscopic variceal ligation. Octreotide infusion is effective for control of variceal bleeding. We investigated the efficacy of octreotide infusion as an adjunct to endoscopic variceal ligation to prevent early rebleeding from varices. 100 consecutive patients admitted with endoscopically confirmed oesophageal varices and active bleeding or signs of recent haemorrhage were randomly assigned endoscopic variceal ligation alone or octreotide (50 micrograms intravenous bolus injection followed by intravenous infusion at 50 micrograms per h for 5 days) plus endoscopic variceal ligation. Three patients in each group were excluded. Bleeding was controlled in 44 of 47 patients who received variceal ligation alone and in 45 of 47 who received combined treatment (p = 1.0). Recurrent bleeding was documented in 18 (38% [24-52]) patients who received variceal ligation alone and in four (9% [3-21] who received combined treatment (p = 0.0007). The relative risk of rebleeding was lower (0.22 [0.08-0.60]) in the combined therapy group. Ten patients in the variceal ligation group and one in the combined therapy group required balloon tamponade for massive haematesis and haemodynamic instability (p = 0.0039). The in-hospital and 30-day mortality rates were higher in the variceal ligation group than in the combined therapy group (19 vs 9% and 23 vs 11%), but the differences did not reach significance. The relative risks of in-hospital (0.5 [0.04=5.3]) and 30-day (0.45 [0.17-1.2]) mortality were lower in the combined therapy group. Octreotide significantly reduces recurrent bleeding and the need for balloon tamponade in patients with variceal haemorrhage treated by endoscopic variceal ligation.

Eradication of Helicobacter pylori infection is known to reduce the incidence of duodenal ulcer recurrence. The most commonly used regimen for H. pylori infection is triple antimicrobial therapy for 1-2 weeks. This treatment is associated with frequent side effects and hence unsatisfactory compliance. As in vitro data showed that H. pylori is sensitive to imipenem, the pharmacokinetics of this drug in the gastric milieu, and the clinical efficacy of imipenem with omeprazole in eradicating H. pylori infection were studied. Imipenem/cilastatin levels in serum, gastric secretion and gastric mucosa were assayed in four patients after intravenous injection of a bolus dose of 500 mg. The serum and gastric secretion levels of imipenem achieved were more than 10 times the minimum inhibitory concentration of the drug for H. pylori. Gastric mucosal levels of imipenem vary considerably with time, which probably indicates rapid elimination of the drug into the gastric lumen. In the second part of this study, imipenem/cilastatin was given intravenously for the first 2 days after diagnosis of H. pylori infection in patients with endoscopically confirmed duodenal ulcers. The patients were also treated with 4 weeks of omeprazole. Clearance of H. pylori was initially achieved at the end of 2 days in 20 out of 22 (91%) patients. However, when the biopsies were repeated at 8 weeks, recurrence of H. pylori infection was evident in 19 cases (86.3%) indicating a failure of eradication. It was concluded that imipenem/cilastatin in combination with omeprazole failed to eradicate H. pylori infection.

There is a strong association between infection with Helicobacter pylori and gastric ulcers that are unrelated to the use of nonsteroidal antiinflammatory medications. We studied the efficacy of antibacterial therapy without medication to suppress gastric acid for the treatment of patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal agents.Patients with gastric ulcers seen on endoscopy and with H. pylori infection confirmed by smear or culture were randomly assigned to receive either a one-week course of antibacterial agents (120 mg of bismuth subcitrate, 500 mg of tetracycline, and 400 mg of metronidazole, each given orally four times a day) or a four-week course of omeprazole (20 mg orally per day). Follow-up endoscopies were performed after five and nine weeks. The patients and their physicians were aware of the treatment assignments, but the endoscopists were not.A total of 100 patients were randomly assigned to treatment, and 85 completed the trial. At five weeks, H. pylori had been eradicated in 41 of the 45 patients in the antibacterial-treatment group (91.1 percent; 95 percent confidence interval, 82.9 to 99.3) and in 5 of the 40 in the omeprazole group (12.5 percent; 95 percent confidence interval, 2.3 to 22.7; P0.001). The gastric ulcers were healed in 38 of the patients treated with antibacterial drugs (84.4 percent; 95 percent confidence interval, 73.9 to 95.0) and in 29 of those treated with omeprazole (72.5 percent; 95 percent confidence interval, 58.6 to 86.4; P = 0.28). At nine weeks, ulcer healing was confirmed in 43 of the patients receiving antibacterial therapy and in 37 of those receiving omeprazole (P = 1.0). The mean (+/- SD) duration of pain during the first week of treatment was 1.9 +/- 2.6 days in the omeprazole group, as compared with 3.6 +/- 3.0 days in the antibacterial-treatment group (P = 0.004). One year after treatment, recurrent gastric ulcers were detected in 1 of 22 patients (4.5 percent) in the antibacterial-treatment group and in 12 of 23 (52.2 percent) in the omeprazole group (P = 0.001). H. pylori was detected in the 1 patient with a recurrent ulcer who had received antibacterial treatment and in 10 of the 12 patients with recurrent ulcers who had received omeprazole.In patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal antiinflammatory drugs, one week of antibacterial therapy without acid suppression heals the ulcers as well as omeprazole and reduces the rate of their recurrence.

Background Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy through a long submucosal tunnel. Objective This study aimed to investigate the feasibility and safety of POEM for treatment of achalasia. Design Preclinical animal study and prospective clinical study. Patients Consecutive patients diagnosed with achalasia with high-resolution manometry. Interventions POEM was standardized for preclinical and clinical studies. After submucosal injection, a mucosal incision was made 15 cm above the gastroesophageal junction (GEJ). A long submucosal tunnel was created to extend below the GEJ. The endoscopic myotomy started 10 cm above and extended 2 cm below the GEJ. We first conducted a preclinical animal study to confirm the safety of POEM. POEM was then performed for the treatment of achalasia in humans. Main Outcome Measurements Relief from dysphagia assessed by the dysphagia score and Eckhardt score. High-resolution manometry and pH monitoring were performed to evaluate the posttreatment effects and esophageal acid exposure. Results Seven 30-kg porcine models underwent POEM in the survival study. All of the pigs survived except 1, which sustained pneumomediastinum. POEM was performed for the treatment of achalasia in 16 patients. The mean operating time was 117.0 ± 34.1 minutes. All patients tolerated food on day 2, with a contrast study confirming no leakage. The median follow-up was 176.5 days (range 98-230 days). The postoperative basal lower esophageal sphincter pressure was significantly reduced (mean reduction, 13.9 ± 14.5 mm Hg; P = .005) and 4-second integrated relaxation pressure of the GEJ (mean reduction, 10.1 ± 7.4 mm Hg; P = .001). Of these patients, 58.3% had a normalized 4-second integrated relaxation pressure, whereas 20% had excessive esophageal acid exposure after the procedure. There was a significant improvement in quality of life 6 months after POEM measured by the Short Form-36 questionnaire. Limitation Small sample size. Conclusions POEM is a feasible, safe, and effective treatment for achalasia. (Clinical trial registration number: NCT01525732.)

To compare octreotide with injection sclerotherapy in the treatment of acute variceal haemorrhage, patients admitted with gastrointestinal bleeding and oesophageal varices confirmed by endoscopy were randomised to receive either emergency sclerotherapy with 3% sodium tetradecyl sulphate or octreotide (50 micrograms intravenous bolus plus 50 micrograms per h intravenous infusion for 48 h). At the end of the study period (48 h), the octreotide group also had sclerotherapy to obliterate the varices. 100 patients were recruited. Demographic features including the aetiology of portal hypertension and the Child-Pugh's grading of the two groups were similar. Bleeding was initially controlled in 90% of patients by emergency sclerotherapy and in 84% by octreotide infusion (95% confidence interval 0-19.5, p = 0.55). There were no significant differences between the two groups in early (within 48 h of randomisation) rebleeding (16% vs 14%), blood transfusion (3 units vs 3.5), hospital stay (5 days vs 6 days), or hospital mortality (27% vs 20%). No notable side-effects were associated with octreotide. We conclude that octreotide infusion and emergency sclerotherapy are equally effective in controlling variceal haemorrhage.

Background: The approach to salvage surgery after failed endoscopic therapy for a bleeding peptic ulcer is controversial. We aimed to compare the outcomes of salvage surgery after failed endoscopic therapy for bleeding peptic ulcers over a 10-year period. Methods: Patients receiving salvage surgery for bleeding peptic ulcers were divided into 2 cohorts, the 1st from 1993 to 1998 and the 2nd from 1999 to 2004. The type of salvage surgery was defined as minimal if ulcer plication or an ulcerectomy was performed, and definitive if the patient received a vagotomy or gastrectomy. Results: One hundred and twenty-three patients received salvage surgery in the 1st cohort, while 42 patients received surgical hemostasis for the bleeding peptic ulcer in the 2nd cohort. Patients in the 2nd cohort consisted of a larger proportion of in-hospital bleeders (cohort 1: 12.2%, cohort 2: 42.9%; p < 0.005) and had a significantly higher proportion of comorbidities. A larger number of patients received minimal surgery in cohort 2 (cohort 1: 42.3%, cohort 2: 73.8%; p < 0.005). Conclusions: With advances in therapeutic endoscopy, patients who developed failed endoscopic hemostasis are likely to be poor surgical candidates with multiple comorbidities. The approach to salvage surgery has inclined towards minimal surgery to hasten surgical hemostasis among these fragile patients.

The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong.Seventy consecutive Chinese patients (49 females; mean age 34.7+/-8.8 [range 18-56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9+/-22.1 kg (range 71.0-164.9 kg) and 40.7+/-7.8 kg/m(2) (range 27.4-68.4 kg/m(2)), respectively. Outcome measures were collected and assessed in a prospective manner.All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1+/-5.0 months. Mean procedure time was 90.6+/-39.4 min, and mean hospital stay was 3.8+/-2.3 days. Mean BMI loss was 6.3+/-2.5, 9.0+/-3.4 and 12.3+/-4.5 kg/m(2) at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5+/-28.4, 69.7+/-31.7, and 63.5+/-29.4 at 3, 6, and 12 months.LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.

We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia.One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner.The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P = 0.008). No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation.Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation.

Background: We evaluated the effectiveness and safety of intragastric balloon (IGB) for the treatment of obesity in ethnic Chinese in Hong Kong. Methods: 15 Chinese patients (10 females; median age 40 years (range 21-58)) completed IGB treatment over a 10-month period since November 2004. Median baseline body weight (BW) and BMI were 100.1 (range 78.5-170.3) kg and 39.4 (range 29.6-56.9) kg/m2 respectively. Coexistent obesity-related morbidities were present in 80% of patients. The Bioenterics Intragastric Balloon (BIB®) was employed, and all placement and removal were performed endoscopically under intravenous conscious sedation. A restricted balanced diet (∼1200 kcal/day) and 150 minutes/week of moderate-intensity exercise were prescribed after balloon placement in a multidisciplinary approach. Outcome measures were collected and assessed in a prospective manner. Results: Median procedure time was 25 (range 19-45) minutes and median hospital stay was 2 (range 1-6) days. Median BW and BMI loss were 15.3 (range 5.3-30.9) kg and 5.6 (range 1.9-12.5) kg/m2 after IGB. The median waist circumference (WC) loss was 9 (range 4-23) cm, and 66.7% of patients were highly satisfied with the treatment. No serious complication related to IGB was observed. Conclusion: IGB is a safe and effective device that achieves moderate weight loss in obese ethnic Chinese patients.

Randomised trials have shown that duodenal ulcers treated by H 2 blockers heal faster if Helicobacter pylori is eradicated concurrently. It remains unknown whether eradication of H pylori without suppression of acid-secretion, is sufficient to allow healing. 153 patients with H pylori infection and duodenal ulcer were randomised to receive either a 1-week course of bismuth subcitrate, tetracycline, and metronidazole (76), or omeprazole for 4 weeks with the same three-drug regimen for the first week (77). Endoscopy and antral biopsies were done at entry and 4 weeks after treatment. 132 patients were suitable for analysis. Duodenal ulcers healed in 60 (92%; 95% Cl 86-100%) patients taking bismuth, tetracycline, and metronidazole compared with 63 (95%; 88-100%) taking omeprazole in addition to the three other drugs. H pylori was eradicated in 61 (94%; 88-100%) who received only three drugs compared with 66 (98%; 96-100%) who received omeprazole as well. Symptoms were reduced more effectively during the first week in patients who received omeprazole (p=0·003). We conclude that a 1-week regimen of bismuth, tetracycline, and metronidazole for patients with H pylori and duodenal ulcer eradicates the organism and heals the ulcer in most patients. Concurrent administration of omeprazole reduces ulcer pain more rapidly but has no effect on ulcer healing.

OBJECTIVE--To determine whether one week's drug treatment is sufficient to eradicate Helicobacter pylori in patients with duodenal ulcer. DESIGN--Single blind, randomised controlled trial. SETTING--Specialised ulcer clinic in a teaching hospital. PATIENTS--155 patients with H pylori and a duodenal ulcer verified endoscopically which had either bled within the previous 24 hours or was causing dyspepsia. INTERVENTIONS--Patients were allocated randomly to receive either omeprazole for four weeks plus bismuth 120 mg, tetracycline 500 mg, and metronidazole 400 mg (all four times a day) for the first week (n = 78), or omeprazole alone for four weeks (n = 77). Further endoscopy was performed four weeks after cessation of all drugs. MAIN OUTCOME MEASURES--Presence or absence of H pylori (by urease testing, microscopy, and culture of antral biopsy specimens), duodenal ulcer, and side effects. RESULTS--Eradication of H pylori occurred in 70 (95%) patients taking the four drugs (95% confidence interval 86% to 97%) compared with three (4%) patients taking omeprazole alone (1% to 11%). Duodenal ulcers were found in four (5%) patients taking the four drugs (2% to 12%) and in 16 (22%) patients taking omeprazole alone (14% to 32%). Mild dizziness was the only reported side effect (six patients in each group) and did not affect compliance. CONCLUSIONS--A one week regimen of bismuth, tetracycline, and metronidazole is safe and effective in eradicating H pylori and reduces the number of duodenal ulcers four weeks after completing treatment.

Background: Azygos blood flow is an index of blood flow through gastroesophageal collateral vessels and varices in portal hypertension. Conventional measurement of azygos blood flow involves catheterization of the azygos vein. We studied the feasibility of assessing azygos blood flow with color Doppler endosonography and of monitoring the effects of vasoactive agents on azygos blood flow. Methods: Patients with portal hypertension were examined by means of linear array color Doppler endoscopic ultrasonography (EUS). Patients who had taken propranolol or nitrates in the 4 weeks before the day of measurement of azygos blood flow were excluded. After identification of the azygos vein and recording of baseline readings of mean arterial blood pressure, pulse rate, and azygos blood flow, patients were selected in a random manner to receive a bolus injection of 2 mg terlipressin, 250 μg somatostatin, or saline solution (control). Azygos blood flow was measured 1, 5, and 10 minutes after injection (AzBF-1, AzBF-5, AzBF-10). Results: Six patients were recruited in each treatment group. Basal azygos blood flow showed a positive association with the Child-Pugh grade of cirrhosis (p < 0.005). After bolus injection of terlipressin and somatostatin, there was a marked decrease in AzBF-1 (24% and 37%), AzBF-5 (42% and 19%), and AzBF-10 (40% both) compared with baseline. The control group showed no significant change in azygos blood flow. Conclusions: Color Doppler EUS is useful in assessing azygos blood flow in portal hypertension and in monitoring the effects of vasoactive agents. (Gastrointest Endosc 1999;50:47-52.)

OBJECTIVE: To compare endoscopic adrenaline injection alone and adrenaline injection plus heat probe for the treatment of actively bleeding peptic ulcers. DESIGN: Randomised prospective study of patients admitted with actively bleeding peptic ulcers. SETTING: One university hospital. SUBJECTS: 276 patients with actively bleeding ulcers detected by endoscopy within 24 hours of admission: 136 patients were randomised to endoscopic adrenaline injection alone and 140 to adrenaline injection plus heat probe treatment. MAIN OUTCOME MEASURES: Initial endoscopic haemostasis; clinical rebleeding; requirement for operation; requirement for blood transfusion; hospital stay, ulcer healing at four weeks; and mortality in hospital. RESULTS: Initial haemostasis was achieved in 131/134 patients (98%) who received adrenaline injection alone and 135/136 patients (99%) who received additional heat probe treatment (P = 0.33). Outcome as measured by clinical rebleeding (12 v 5), requirement for emergency operation (14 v 8), blood transfusion (2 v 3 units), hospital stay (4 v 4 days), ulcer healing at four weeks (79.1% v 74%), and in hospital mortality (7 v 8) were not significantly different in the two groups. In the subgroup of patients with spurting haemorrhage 8/27 (29.6%; 14.5% to 50.3%) patients from the adrenaline injection alone group and 2/31 (6.5%; 1.1% to 22.9%) patients from the dual treatment group required operative intervention. The relative risk of this was lower in the dual treatment group (0.17; 0.03 to 0.87). Hospital stay was significantly shorter in the dual treatment group than the adrenaline injection alone group (4 v 6 days, P = 0.01). CONCLUSION: The addition of heat probe treatment after endoscopic adrenaline injection confers an advantage in ulcers with spurting haemorrhage.

determinant of the need to tailor the type of fundoplication. The aim of this study was to determine normal values for the RBP in asymptomatic subjects and in patients before and after a Nissen fundoplication. Methods: The ramp bolus pressure (RBP) was determined by measuring the mean pressure preceding the upstroke of the contraction wave 5cm above the lower esophageal sphincter (LES) (Figure). We measured the RBP in 53 asymptomatic volunteers and 37 patients with reflux symptoms before and after a Nissen fundoplication. All of the reflux patients had an excellent outcome and none had dysphagia at the time of postoperative evaluation. Results: A RBP was present in 97% of normal subjects and 100% of patients. The mean (SD) amplitude of the RBP in normal subjects was 6.8 (3.7) mmHg. The RBP in reflux patients was significantly lower than that in normal subjects [3.6 (7.0) mmHg, p