role of the normal gut microbiota Jandhyala, Sai Manasa; Talukdar, Rupjyoti; Subramanyam, Chivkula ...
World journal of gastroenterology : WJG,
08/2015, Letnik:
21, Številka:
29
Journal Article
Odprti dostop
Relation between the gut microbiota and humanhealth is being increasingly recognised. It is nowwell established that a healthy gut flora is largelyresponsible for overall health of the host. The ...normalhuman gut microbiota comprises of two major phyla,namely Bacteroidetes and Firmicutes. Though thegut microbiota in an infant appears haphazard, itstarts resembling the adult flora by the age of 3years. Nevertheless, there exist temporal and spatialvariations in the microbial distribution from esophagusto the rectum all along the individual＇s life span.Developments in genome sequencing technologies andbioinformatics have now enabled scientists to studythese microorganisms and their function and microbehostinteractions in an elaborate manner both in healthand disease. The normal gut microbiota imparts specificfunction in host nutrient metabolism, xenobiotic anddrug metabolism, maintenance of structural integrityof the gut mucosal barrier, immunomodulation, andprotection against pathogens. Several factors play arole in shaping the normal gut microbiota. They include（1） the mode of delivery （vaginal or caesarean）; （2）diet during infancy （breast milk or formula feeds）and adulthood （vegan based or meat based）; and （3）use of antibiotics or antibiotic like molecules that arederived from the environment or the gut commensalcommunity. A major concern of antibiotic use isthe long-term alteration of the normal healthy gutmicrobiota and horizontal transfer of resistance genesthat could result in reservoir of organisms with amultidrug resistant gene pool.
Background
Peroral endoscopic myotomy (POEM) is an evolving therapeutic modality for achalasia. We aim to determine efficacy of POEM for the treatment of achalasia and compare it with laparoscopic ...Heller’s myotomy (LHM).
Materials and methods
Systematic review and meta-analyses was conducted on 19 studies using POEM for achalasia. Pubmed, Medline, Cochrane, and Ovid databases, were searched using the terms ‘achalasia’, ‘POEM’, ‘peroral endoscopic myotomy’, ‘per oral endoscopic myotomy’, and ‘per-oral endoscopic myotomy’. Reduction in Eckhart’s score and lower esophageal sphincter (LES) pressure were the main outcome measures.
Results
A total of 1,045 patients underwent POEM in 29 studies. Ninety patients undergoing POEM was compared with 160 undergoing LHM in five studies. Nineteen and 14 studies, respectively, evaluated for Eckhart’s score and LES pressure. There was significant reduction in Eckhart’s score and LES pressure with effect sizes of −7.95 (
p
< 0.0001) and −7.28 (
p
< 0.0001), respectively. There was significant heterogeneity among the studies (
Q
= 83.06;
I
2
= 78.33 %;
p
< 0.0001) for Eckhart’s score and (
Q
= 61.44;
I
2
= 75.68 %;
p
< 0.0001) for LES pressure. There were no differences between POEM and LHM in reduction in Eckhart’s score, post-operative pain scores and analgesic requirements, length of hospital stay, adverse events, and symptomatic gastroesophageal reflux/reflux esophagitis. Operative time was significantly lower for POEM.
Conclusions
POEM is effective for achalasia and has similar outcomes as LHM. Multicenter randomized trials need to be conducted to further compare the efficacy and safety of POEM between treatment naïve achalasia patients and those who failed treatment.
Background and Aims Insulinomas are one of the most common functional pancreatic neuroendocrine tumors. Surgical removal is the standard of care. Patients unfit for or refusing surgery need an ...alternative nonsurgical method to alleviate symptoms. EUS has been used to localize, aspirate, and tattoo insulinomas and to inject alcohol for local ablation. This study is aimed at assessing the feasibility of EUS-guided radiofrequency ablation (EUS-RFA) for managing patients with a symptomatic insulinoma by using a novel EUS-RFA needle electrode. Methods The EUS-RFA system used consists of a prototype 19-gauge needle electrode, generator, and internal cooling system. EUS-guided RFA is performed under real-time visualization at 50 W to ablate pancreatic insulinomas. Results In this observational human case series from a tertiary care center, 3 patients with a symptomatic pancreatic insulinoma, not eligible for surgery, underwent EUS-RFA by using an internally cooled prototype needle electrode. All had rapid symptom relief with biochemical improvement and remained symptom free at 11 to 12 months of follow-up. There were no procedure-related adverse events. Conclusions EUS-RFA with the novel device can be considered in select patients with a symptomatic pancreatic insulinoma based on preliminary findings of a beneficial effect without adverse events. Assessment of the safety profile requires larger prospective trials.
Accurately diagnosing indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy sampling under direct cholangioscopic vision might be ...superior to standard ERCP techniques such as brushing or biopsy sampling. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP workup improves the diagnostic yield in patients with indeterminate biliary strictures.
Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (control arm CA) or DSOC visualization and DSOC-guided biopsy sampling (study arm SA). This was a prospective, international, multicenter trial with a procedure-blinded pathologist.
The first sample sensitivity of DSOC-guided biopsy samples was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P < .01). The sensitivity of visualization (SA 95.5% vs CA 66.7%, P = .02) and overall accuracy (SA 87.1% vs CA 65.5%, P = .05) were significantly higher in the SA compared with the CA, whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms.
DSOC-guided biopsy sampling was shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathologic diagnosis of indeterminate biliary strictures. (Clinical trial registration number: NCT 03140007.)
Coronavirus-19 (COVID-19) caused by SARS-CoV-2 has become a global pandemic. Risk of transmission may occur during endoscopy and the goal is to prevent infection among healthcare professionals while ...providing essential services to patients. Asia was the first continent to have a COVID-19 outbreak, and this position statement of the Asian Pacific Society for Digestive Endoscopy shares our successful experience in maintaining safe and high-quality endoscopy practice at a time when resources are limited. Sixteen experts from key societies of digestive endoscopy in Asia were invited to develop position statements, including patient triage and risk assessment before endoscopy, resource prioritisation and allocation, regular monitoring of personal protective equipment, infection control measures, protective device training and implementation of a strategy for stepwise resumption of endoscopy services after control of the COVID-19 outbreak.
Background Currently available techniques to diagnose indeterminate biliary lesions have many limitations. Objective To assess the accuracy of single-operator peroral cholangioscopy by using the ...SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions. Design Prospective, single-arm, single-center study. Setting Tertiary referral center. Patients Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling. Interventions SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies. Main Outcome Measurements Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions. Results Thirty-six patients (22 men, mean age 48.3 years range 27-68 years) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis. Limitations No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures. Conclusions SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.
Background and Aims EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal ...stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic “step-up approach” for drainage of symptomatic WON. Methods We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN. Results Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2). Conclusions The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.
Endoscopic ultrasonography (EUS)-guided pancreatic pseudocyst drainage using a self-expandable metal stent (SEMS) has been reported for satisfactory drainage and endoscopic necrosectomy. Here, we ...described an interesting case in which successful endoscopic therapy was performed using a new SEMS in infectious walled-off pancreatic necrosis.
Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there ...is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per‐oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short‐term to mid‐term follow‐up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective ...β-blocker; PPI, proton pump inhibitors.
Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
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