Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe postprocedure complications. Hormonal changes during pregnancy promote cholelithiasis, but there are limited clinical data available on the outcomes of ERCP in pregnant women. ERCP techniques without irradiation were recently introduced as potential alternative. We performed a systematic review and meta-analysis to assess the safety of ERCP in pregnancy and to compare outcomes of radiation versus nonradiation ERCP. Materials and Methods: A systematic search of PubMed, Medline/Ovid, Web of Science, and Google Scholar through April 18^th, 2018 using PRISMA and MOOSE guidelines identified 27 studies reporting the outcomes of ERCP in pregnancy. Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I², and meta-regression analysis was conducted. Adverse outcomes were divided into fetal, maternal pregnancy-related, and maternal nonpregnancy-related. Results: In all, 27 studies reporting on 1,307 pregnant patients who underwent ERCP were identified. Median age was 27.1 years. All results were statistically significant (P < 0.01). The pooled event rate for overall adverse outcomes was 15.9% (95% CI = 0.132–0.191) in all studies combined, 17.6% (95% CI = 0.109–0.272) in nonradiation ERCP (NR-ERCP) subgroup and 21.6% (95% CI = 0.154–0.294) in radiation ERCP subgroup. There was no significant difference in the pooled event rate for fetal adverse outcomes in NR-ERCP 6.2% (95% CI = 0.027–0.137) versus 5.2% (95% CI = 0.026–0.101) in radiation ERCP group. There was no significant difference in maternal pregnancy-related adverse outcome event rate between NR-ERCP (8.4%) (95% CI = 0.038–0.173) and radiation ERCP (7.1%) (95% CI = 0.039–0.125). Maternal nonpregnancy-related adverse outcome event rate in NR-ERCP was 7.6% (95% CI = 0.038–0.145), which was half the event rate in radiation ERCP group of 14.9% (95% CI = 0.102–0.211). Conclusions: ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy-related complications, but not of fetal and pregnancy-related complications.

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Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II gastrectomy patients is technically demanding and factors affecting its technical difficulty have not yet been clarified. This study aimed to investigate the outcomes of ERCP in Billroth II gastrectomy patients and identify potential factors affecting its technical failure. Patients and Methods: A large retrospective study of 308 consecutive patients (391 procedures) with Billroth II gastrectomy—who underwent ERCP from January 2002 to December 2016—was conducted. The outcomes of ERCP and potential factors affecting its technical failure were analyzed. Results: The success rate of duodenal ampullary access, selective duct cannulation and the accomplishment of expected procedures was 81.3% (318/391), 86.5% (275/318) and 97.3% (256/263), respectively, and the technical success rate was 70.3% (275/391). The overall ERCP-related complication rate was 15.3% (60/391). The multivariate analysis indicated that first-time ERCP attempt [odds ratio (OR) 4.29, 95% confidence interval (CI) 2.34–7.85, P < 0.001], Braun anastomosis (OR 3.65, 95% CI 1.38–9.64, P < 0.009), and no cap-assisted gastroscope (OR 3.05, 95% CI 1.69–5.51, P < 0.001) were significantly associated with technical failure. Conclusions: ERCP is safe, effective and feasible for Billroth II gastrectomy patients. Previous ERCP history, absence of Braun anastomosis and the use of a cap-assisted gastroscope are the predictive factors for its technical success.

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Background/Aims: To assess the frequency of and risk factors for intolerance to enteral nutrition through nasogastric (NG) or nasojejunal (NJ) tube feeding in patients with moderately severe acute pancreatitis. Patients and Methods: Patients who underwent enteral nutrition via the nasojejunal tube or nasogastric tube, from January 2012 to December 2017, were enrolled. Demographic and etiological data, admission variables, enteral nutrition related variables, and radiological variables were evaluated using univariate and multivariate analysis. Results: A total of 568 patients were included, with 235 (41.4%) receiving nasojejunal tube feeding and 333 (56.8%) receiving nasogastric tube feeding. Tube-feeding intolerance was observed in 184 patients (32.4%), occurring at a median of 3 days (range, 1-5 days) after the start of enteral nutrition. The variables independently associated with risk of intolerance to tube feeding were hypertriglyceridemia (odds ratio, 8.13;95% CI, 5.21-10.07; P = 0.002), the presence of systemic inflammatory response syndrome (odds ratio, 6.58;95% CI, 3.03-8.34; P = 0.002), acute gastrointestinal injury-III status (odds ratio, 5.51;95% CI, 2.30-7.33; P = 0.02), the time from admission to commencement of enteral nutrition (odds ratio, 7.21;95% CI, 2.16-9.77; P = 0.001), and pancreatic infection (odds ratio, 6.15;95% CI, 4.94-8.75; P = 0.002) Patients with tube-feeding intolerance required prolonged enteral nutrition (P < 0.001) and had longer hospitalizations (P < 0.001). Conclusions: Tube-feeding intolerance accounts for a considerable proportion in patients with moderately severe acute pancreatitis. The presence of hypertriglyceridemia, systemic inflammatory response syndrome and acute gastrointestinal injury grade III or pancreatic infection and the time from admission to commencing enteral nutrition increase the risk for tube-feeding intolerance.

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Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

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Background/Aim: The prognosis of hepatocellular carcinoma (HCC) is very dismal and the targeted drugs of HCC are limited. Studies of HCC prognostic biomarkers have made little progress, though many new techniques such as high-throughput sequencing have been applied. FOS-like antigen 1 (FOSL1) is generally accepted as a proto-oncogene but its clinical significance in HCC has never been elucidated. Materials and Methods: In our study, we investigated the expression of FOSL1 in 114 paraffin-embedded HCC tissues, and detected FOSL1 mRNA levels in 20 pairs of fresh HCC tissues and their corresponding tumor adjacent tissues. The correlations between FOSL1 expression and clinicopathological factors were analyzed and the prognostic significance of FOSL1 was evaluated with univariate and multivariate analysis. Moreover, we detected the function of FOSL1 in HCC proliferation with experiments in vitro. Results: FOSL1 mRNAs in HCCs were significantly higher than those in tumor adjacent tissues. The percentage of high expression and low expression of FOSL1 accounted for 46% (53/114) and 54% (61/114), respectively. High expression of FOSL1 was significantly associated with larger tumor size (P = 0.021), hepatitis B virus infection (P = 0.014), advanced T stage (P = 0.014), and tumor necrosis metastasis stage (P = 0.014). Moreover, high expression of FOSL1 was significantly correlated with poor prognosis of HCC and could be identified as an independent prognostic biomarker of HCC (hazard ratio = 5.60, 95% confidence interval = 3.00–10.45, P < 0.001). With in vitro function assay, we demonstrated that FOSL1 played an essential role in HCC proliferation. Conclusions: High expression of FOSL1 is an independent risk factor of HCC predicting unfavorable prognosis, indicating that FOSL1 detection could stratify patients with high risk, and anti-FOSL1 therapy may be a promising way to treat HCC.

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Background/Aim: Cecal intubation during colonoscopy is prone to be prolonged in women, which may be related to frequent exposure to pelvic/abdominal surgery. We evaluated the association between Cecal Intubation Time (CIT) and prior episodes of pelvic/abdominal surgery in women. Patients and Methods: A cross-sectional study was conducted on screening participants who underwent colonoscopy. Multivariate regression with parameter estimates (β) was performed to determine the factors affecting CIT, including age, body mass index (BMI), bowel preparation, sedation, diverticulosis, experience of colonoscopists, and a surgical history. Also, subgroup analyses according to type of surgery were performed. Results: A total of 835 women were enrolled. The mean CIT was 5.82 ± 3.40 min. 323 females (38.7%) had episodes of surgery. The CIT was prolonged in cases performed by non-experienced trainees (β = 3.61, P< 0.001) and with a history of gynecological surgery (β = 0.97, P = 0.001). In the subgroup of non-experienced trainees, lower BMI, poor preparation, and a history of cesarean section significantly prolonged the CIT. Also, the risk for difficult colonoscopy (CIT ≥ 15 min) was increased with a history of cesarean section (odds ratio = 4.43, P= 0.024). Conclusion: A prior episode of gynecological surgery prolonged CIT. Also, cesarean section history was associated with difficult colonoscopy in the examination by non-experienced trainees.

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Background / Aims:Clostridium difficile is a Gram-positive, strict anaerobe, spore-forming bacterium. It can cause self-limiting mild diarrhea, severe diarrhea, pseudomembranous colitis, and fatal fulminant colitis. We aimed to investigate the changes in epidemiology and incidence of C. difficile infection in our hospital database. Patients and Methods: Episodes of C. difficile toxin were identified in hospital database, and data such as age, sex, community versus hospital acquisition, intensive care follow-up, current or previous treatments with antibiotics within the past 3 months, medication with proton pump inhibitors, or immunosuppressive therapies were collected. Results: Toxin-positive 78 individuals constituted the patient group. In univariate analyses, independent risk factors for toxin positivity were community versus hospital acquisition [odds ratio (OR), 5.49; 95% confidence interval (CI), 2.52–11.95; P = 0.0001], presence of inflammatory bowel diseases (IBDs) (OR, 21.5; 95% CI, 8.65–53.44; P = 0.0001), proton pump inhibitors' use (OR, 4.53; 95% CI, 1.97–10.43; P = 0.0001), immunosuppressive drug use (OR, 4.1; 95% CI, 2.01–8.3; P = 0.0001), and use of quinolone group of antibiotics (OR, 5.95; 95% CI, 1.92–18.46; P = 0.001). Antibiotic use was a protective risk factor (OR, 0.09; 95% CI, 0.01–0.78; P = 0.01) and presence of IBDs was an independent risk factor (OR, 6.8; 95% CI, 1.5–30.08; P = 0.01) in community-acquired group (OR, 0.09; 95% CI, 0.01–0.78; P = 0.01). Conclusion: In recent studies, C. difficile infections were demonstrated to be more frequent in younger individuals who did not have a history of hospitalization but had an underlying disease such as IBD. In our study, we showed the change in the epidemiological data with prominence of underlying diseases such as IBDs.

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Background/Aims: We aimed to investigate incidence, characteristics, and possible risk factors of pancreatic cancer in patients under observation for hepatocellular carcinoma (HCC) because the association of hepatitis virus B infection and pancreatic cancer has been reported. Patients and Methods: We performed a retrospective cohort study in the Gastroenterology Department of a University Hospital in Japan between 2004 and 2012. A total of 1848 patients who underwent treatment for HCC were included at the initiation of treatment for HCC (mean follow-up period, 33.6 months). The patients received trimonthly radiological follow-ups. Newly developed cases of pancreatic cancer during follow-up for HCC were compared with that of an age- and sex-matched theoretical cohort from national statistics. Possible predisposing factors for pancreatic cancer related to HCC were assessed. Cumulative probabilities of developing a pancreatic cancer were compared using log-rank test. Results: About 13 of 1848 patients developed pancreatic cancer (mean follow-up period, 45.2 months). The risk ratio for all patients was 3.02 (log-rank test: P =0.01). Statistical analyses showed no effects of the following factors on the development of pancreatic cancer: age, sex, follow-up period, alcohol intake, laboratory data, presence of hepatitis virus, characteristics of HCC, type of treatment, number of radiological examinations, and cumulative effective dose. Conclusions: Increased incidence of pancreatic cancer was found in patients under observation for HCC in a relatively small cohort. HCC or other common underlying conditions might be a risk factor for development of pancreatic cancer.

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