18 - World Journal of Gastroenterology
18 - World Journal of Gastroenterology
18 - World Journal of Gastroenterology
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<strong>World</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Gastroenterology</strong><br />
Indexed and Abstracted in:<br />
Current Contents ® /Clinical Medicine, Science<br />
Citation Index Expanded (also known as<br />
SciSearch ® ) and <strong>Journal</strong> Citation Reports/Science<br />
Edition, Index Medicus, MEDLINE and PubMed,<br />
Chemical Abstracts, EMBASE/Excerpta Medica,<br />
Abstracts <strong>Journal</strong>s, Nature Clinical Practice<br />
<strong>Gastroenterology</strong> and Hepatology, CAB Abstracts<br />
and Global Health.<br />
ISI JCR 2003-2000 IF: 3.3<strong>18</strong>, 2.532, 1.445 and 0.993.<br />
A Weekly <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> and Hepatology<br />
Volume 13 Number <strong>18</strong><br />
May 14, 2007<br />
<strong>World</strong> J Gastroenterol<br />
2007 May 14; 13(<strong>18</strong>): 2523-2648<br />
Online Submissions<br />
www.wjgnet.com/wjg/index.jsp<br />
www.wjgnet.com<br />
Printed on Acid-free Paper<br />
ISSN 1007-9327<br />
CN 14-1219/R
HONORARY EDITORS-IN-CHIEF<br />
Ke-Ji Chen, Beijing<br />
Li-Fang Chou, Taipei<br />
Zhi-Qiang Huang, Beijing<br />
Shinn-Jang Hwang, Taipei<br />
Min-Liang Kuo, Taipei<br />
Nicholas F LaRusso, Rochester<br />
Jie-Shou Li, Nanjing<br />
Geng-Tao Liu, Beijing<br />
Lein-Ray Mo, Tainan<br />
Bo-Rong Pan, Xi'an<br />
Fa-Zu Qiu, Wuhan<br />
Eamonn M Quigley, Cork<br />
David S Rampton, London<br />
Rudi Schmid, Kentfi eld<br />
Nicholas J Talley, Rochester<br />
Guido NJ Tytgat, Amsterdam<br />
H-P Wang, Taipei<br />
Jaw-Ching Wu, Taipei<br />
Meng-Chao Wu, Shanghai<br />
Ming-Shiang Wu, Taipei<br />
Jia-Yu Xu, Shanghai<br />
Ta-Sen Yeh, Taoyuan<br />
EDITOR-IN-CHIEF<br />
Lian-Sheng Ma, Taiyuan<br />
ASSOCIATE EDITORS-IN-CHIEF<br />
Gianfranco D Alpini, Temple<br />
Bruno Annibale, Roma<br />
Roger William Chapman, Oxford<br />
Chi-Hin Cho, Hong Kong<br />
Alexander L Gerbes, Munich<br />
Shou-Dong Lee, Taipei<br />
Walter Edwin Longo, New Haven<br />
You-Yong Lu, Beijing<br />
Masao Omata, Tokyo<br />
Harry HX Xia, Hanover<br />
MEMBERS OF THE EDITORIAL<br />
BOARD<br />
Albania<br />
Bashkim Resuli, Tirana<br />
<strong>World</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Gastroenterology</strong><br />
Editorial Board<br />
2007-2009<br />
Baishideng<br />
http://www.wjgnet.com E-mail: wjg@wjgnet.com<br />
Argentina<br />
Julio Horacio Carri, Córdoba<br />
Adriana M Torres, Rosario<br />
Australia<br />
Minoti Vivek Apte, Liverpool<br />
Richard B Banati, Lidcombe<br />
Michael R Beard, Adelaide<br />
Patrick Bertolino, Sydney<br />
Filip Braet, Sydney<br />
Andrew D Clouston, Sydney<br />
Darrell HG Crawford, Brisbane<br />
Guy D Eslick, Sydney<br />
Michael Anthony Fink, Melbourne<br />
Robert JL Fraser, Daw Park<br />
Mark D Gorrell, Sydney<br />
Yik-Hong Ho, Townsville<br />
Gerald J Holtmann, Adelaide<br />
Michael Horowitz, Adelaide<br />
John E Kellow, Sydney<br />
Daniel Markovich, Brisbane<br />
Phillip S Oates, Perth<br />
Stephen M Riordan, Sydney<br />
IC Roberts-Thomson, Adelaide<br />
Arthur Shulkes, Melbourne<br />
Ross C Smith, Sydney<br />
Kevin John Spring, Brisbane<br />
Nathan Subramaniam, Brisbane<br />
Herbert Tilg, Innsbruck<br />
Martin John Veysey, Gosford<br />
DL Worthley, Bedford<br />
Austria<br />
Valentin Fuhrmann, Vienna<br />
Alfred Gangl, Vienna<br />
Christoph Gasche, Vienna<br />
Kurt Lenz, Linz<br />
M Peck-Radosavljevic, Vienna<br />
RE Stauber, Auenbruggerplatz<br />
Michael Trauner, Graz<br />
Harald Vogelsang, Vienna<br />
Guenter Weiss, Innsbruck<br />
Belarus<br />
Yury K Marakhouski, Minsk<br />
www.wjgnet.com<br />
Belgium<br />
Rudi Beyaert, Gent<br />
Bart Rik De Geest, Leuven<br />
Inge Irma Depoortere, Leuven<br />
Olivier Detry, Liège<br />
BY De Winter, Antwerp<br />
Karel Geboes, Leuven<br />
Thierry Gustot, Brussels<br />
Yves J Horsmans, Brussels<br />
Geert G Leroux-Roels, Ghent<br />
Louis Libbrecht, Leuven<br />
Etienne M Sokal, Brussels<br />
Marc Peeters, De Pintelaan<br />
Gert A Van Assche, Leuven<br />
Yvan Vandenplas, Brussels<br />
Eddie Wisse, Keerbergen<br />
Brazil<br />
Heitor Rosa, Goiania<br />
Bulgaria<br />
Zahariy Krastev, S<strong>of</strong>i a<br />
Canada<br />
Fernando Alvarez, Québec<br />
David Armstrong, Ontario<br />
Olivier Barbier, Québec<br />
Nancy Baxter, Toronto<br />
Matthew Bjerknes, Toronto<br />
Frank J Burczynski, Winnipeg<br />
Michael F Byrne, Vancouver<br />
Wang-Xue Chen, Ottawa<br />
Hugh J Freeman, Vancouver<br />
Chantal Guillemette, Québec<br />
Samuel S Lee, Calgary<br />
Gary A Levy, Toronto<br />
Andrew Lawrence Mason, Alberta<br />
John K Marshall, Ontario<br />
Donna-Marie McCafferty, Calgary<br />
Thomas I Michalak, St. John's<br />
Gerald Y Minuk, Manitoba<br />
Paul Moayyedi, Hamilton<br />
Eldon Shaffer, Calgary<br />
Morris Sherman, Toronto<br />
Alan BR Thomson, Edmonton<br />
EF Verdu, Ontario<br />
I
Ⅱ<br />
John L Wallace, Calgary<br />
Eric M Yoshida, Vancouver<br />
Chile<br />
Silvana Zanlungo, Santiago<br />
China<br />
Henry LY Chan, Hongkong<br />
Xiao-Ping Chen, Wuhan<br />
Zong-Jie Cui, Beijing<br />
Da-Jun Deng, Beijing<br />
Er-Dan Dong, Beijing<br />
Sheung-Tat Fan, Hong Kong<br />
Jin Gu, Beijing<br />
De-Wu Han, Taiyuan<br />
Ming-Liang He, Hong Kong<br />
Wayne HC Hu, Hong Kong<br />
Chee-Kin Hui, Hong Kong<br />
Ching Lung Lai, Hong Kong<br />
Kam Chuen Lai, Hong Kong<br />
James YW Lau, Hong Kong<br />
Yuk Tong Lee, Hong Kong<br />
Suet Yi Leung, Hong Kong<br />
Wai-Keung Leung, Hong Kong<br />
Chung-Mau Lo, Hong Kong<br />
Jing-Yun Ma, Beijing<br />
Lun-Xiu Qin, Shanghai<br />
Yu-Gang Song, Guangzhou<br />
Qin Su, Beijing<br />
Wai-Man Wong, Hong Kong<br />
Hong Xiao, Beijing<br />
Dong-Liang Yang, Wuhan<br />
Winnie Yeo, Hong Kong<br />
Yuan Yuan, Shenyang<br />
Man-Fung Yuen, Hong Kong<br />
Jian-Zhong Zhang, Beijing<br />
Xin-Xin Zhang, Shanghai<br />
Shu Zheng, Hangzhou<br />
Croatia<br />
Tamara Cacev, Zagreb<br />
Marko Duvnjak, Zagreb<br />
Cuba<br />
Damian Casadesus Rodriguez, Havana<br />
Czech<br />
Milan Jirsa, Praha<br />
Denmark<br />
Peter Bytzer, Copenhagen<br />
Hans Gregersen, Aalborg<br />
Jens H Henriksen, Hvidovre<br />
Claus Peter Hovendal, Odense<br />
Fin Stolze Larsen, Copenhagen<br />
SØren MØller, Hvidovre<br />
Egypt<br />
Abdel-Rahman El-Zayadi, Giza<br />
Amr Mohamed Helmy, Cairo<br />
Sanaa Moharram Kamal, Cairo<br />
Ayman Yosry, Cairo<br />
Finland<br />
Irma Elisabet Jarvela, Helsinki<br />
Katri Maria Kaukinen, Tampere<br />
Minna Nyström, Helsinki<br />
Pentti Sipponen, Espoo<br />
France<br />
Bettaieb Ali, Dijon<br />
Corlu Anne, Rennes<br />
Denis Ardid, Clermont-Ferrand<br />
Charles Paul Balabaud, Bordeaux<br />
Soumeya Bekri, Rouen<br />
Jacques Belghiti, Clichy<br />
Pierre Brissot, Rennes<br />
Patrice Philippe Cacoub, Paris<br />
Franck Carbonnel, Besancon<br />
Laurent Castera, Pessac<br />
Bruno Clément, Rennes<br />
Jacques Cosnes, Paris<br />
Thomas Decaens, Cedex<br />
Francoise Lunel Fabiani, Angers<br />
Gérard Feldmann, Paris<br />
Jean Fioramonti, Toulouse<br />
Catherine Guettier, Villejuif<br />
Chantal Housset, Paris<br />
Juan Lucio Iovanna, Marseille<br />
Rene Lambert, Lyon<br />
Philippe Mathurin, Lille<br />
Tamara Matysiak–Budnik, Paris<br />
Francis Mégraud, Bordeaux<br />
Richard Moreau, Clichy<br />
Thierry Piche, Nice<br />
Raoul Poupon, Paris<br />
Jean Rosenbaum, Bordeaux<br />
Jose Sahel, Marseille<br />
Jean-Philippe Salier, Rouen<br />
Jean-Yves Scoazec, Lyon<br />
Khalid Ahnini Tazi, Clichy<br />
Emmanuel Tiret, Paris<br />
Baumert F Thomas, Strasbourg<br />
MC Vozenin-brotons, Villejuif<br />
Jean-Pierre Henri Zarski, Grenoble<br />
Jessica Zucman-Rossi, Paris<br />
Germany<br />
HD Allescher, Garmisch-Partenkirchen<br />
Martin Anlauf, Kiel<br />
Rudolf Arnold, Marburg<br />
Max G Bachem, Ulm<br />
Thomas F Baumert, Freiburg<br />
Daniel C Baumgart, Berlin<br />
Hubert Blum, Freiburg<br />
Thomas Bock, Tuebingen<br />
Katja Breitkopf, Mannheim<br />
Dunja Bruder, Braunschweig<br />
Markus W Büchler, Heidelberg<br />
Christa Buechler, Regensburg<br />
Reinhard Buettner, Bonn<br />
Elke Cario, Essen<br />
CF Dietrich, Bad Mergentheim<br />
Rainer Josef Duchmann, Berlin<br />
Paul Enck, Tuebingen<br />
Fred Fändrich, Kiel<br />
Ulrich Robert Fölsch, Kiel<br />
Helmut Friess, Heidelberg<br />
Peter R Galle, Mainz<br />
Nikolaus Gassler, Aachen<br />
Andreas Geier, Aachen<br />
Dieter Glebe, Giessen<br />
Burkhard Göke, Munich<br />
Florian Graepler, Tuebingen<br />
Axel M Gressner, Aachen<br />
Veit Gülberg, Munich<br />
Rainer Haas, Munich<br />
Eckhart Georg Hahn, Erlangen<br />
Stephan Hellmig, Kiel<br />
Martin Hennenberg, Bonn<br />
Johannes Herkel, Hamburg<br />
Klaus Herrlinger, Stuttgart<br />
Eberhard Hildt, Berlin<br />
Joerg C H<strong>of</strong>fmann, Berlin<br />
Ferdinand H<strong>of</strong>staedter, Regensburg<br />
Werner Hohenberger, Erlangen<br />
RG Jakobs, Ludwigshafen<br />
Jutta Keller, Hamburg<br />
Andrej Khandoga, Munich<br />
Sibylle Koletzko, München<br />
Stefan Kubicka, Hannover<br />
Joachim Labenz, Siegen<br />
Frank Lammert, Bonn<br />
Thomas Langmann, Regensburg<br />
Christian Liedtke, Aachen<br />
Matthias Löhr, Mannheim<br />
Christian Maaser, Muenster<br />
Ahmed Madisch, Dresden<br />
www.wjgnet.com<br />
Michael Peter Manns, Hannover<br />
Stephan Miehlke, Dresden<br />
Sabine Mihm, Göttingen<br />
Silvio Nadalin, Essen<br />
Markus F Neurath, Mainz<br />
Johann Ockenga, Berlin<br />
Florian Obermeier, Regensburg<br />
Gustav Paumgartner, Munich<br />
Ulrich Ks Peitz, Magdeburg<br />
Markus Reiser, Bochum<br />
Steffen Rickes, Magdeburg<br />
Gerhard Rogler, Regensburg<br />
Tilman Sauerbruch, Bonn<br />
Dieter Saur, Munich<br />
Hans Scherubl, Berlin<br />
Joerg Schirra, Munich<br />
Roland M Schmid, München<br />
Volker Schmitz, Bonn<br />
AG Schreyer, Regensburg<br />
Tobias Schroeder, Essen<br />
Hans Seifert, Oldenburg<br />
Manfred V Singer, Mannheim<br />
Gisela Sparmann, Rostock<br />
Jurgen M Stein, Frankfurt<br />
Ulrike Susanne Stein, Berlin<br />
Manfred Stolte, Bayreuth<br />
Christian P Strassburg, Hannover<br />
WR Stremmel, Heidelberg<br />
Harald F Teutsch, Ulm<br />
Robert Thimme, Freiburg<br />
HL Tillmann, Leipzig<br />
Tung-Yu Tsui, Regensburg<br />
Axel Ulsenheimer, Munich<br />
Patrick Veit, Essen<br />
Claudia Veltkamp, Heidelberg<br />
Siegfried Wagner, Deggendorf<br />
Henning Walczak, Heidelberg<br />
Fritz von Weizsacker, Berlin<br />
Jens Werner, Heidelberg<br />
Bertram Wiedenmann, Berlin<br />
Reiner Wiest, Regensburg<br />
Stefan Wirth, Wuppertal<br />
Stefan JP Zeuzem, Homburg<br />
Greece<br />
Elias A Kouroumalis, Heraklion<br />
Ioannis E Koutroubakis, Heraklion<br />
Spiros Sgouros, Athens<br />
Hungary<br />
Peter Laszlo Lakatos, Budapest<br />
Zsuzsa Szondy, Debrecen<br />
Iceland<br />
H Gudjonsson, Reykjavik<br />
India<br />
KA Balasubramanian, Vellore<br />
Sujit K Bhattacharya, Kolkata<br />
Yogesh K Chawla, Chandigarh<br />
Radha K Dhiman, Chandigarh<br />
Sri Prakash Misra, Allahabad<br />
ND Reddy, Hyderabad<br />
Iran<br />
Seyed-Moayed Alavian, Tehran<br />
Reza Malekzadeh, Tehran<br />
Seyed Alireza Taghavi, Shiraz<br />
Ireland<br />
Billy Bourke, Dublin<br />
Ronan A Cahill, Cork<br />
Anthony P Moran, Galway<br />
Israel<br />
Simon Bar-Meir, Hashomer<br />
Abraham Rami Eliakim, Haifa
Yaron Ilan, Jerusalem<br />
Avidan U Neumann, Ramat-Gan<br />
Yaron Niv, Pardesia<br />
Ran Oren, Tel Aviv<br />
Italy<br />
Giovanni Addolorato, Roma<br />
Luigi E Adinolfi , Naples<br />
Domenico Alvaro, Rome<br />
V Annese, San Giovanni Rotond<br />
Adolfo Francesco Attili, Roma<br />
Giovanni Barbara, Bologna<br />
Gabrio Bassotti, Perugia<br />
Pier Maria Battezzati, Milan<br />
Stefano Bellentani, Carpi<br />
Antomio Benedetti, Ancona<br />
Mauro Bernardi, Bologna<br />
Livia Biancone, Rome<br />
Luigi Bonavina, Milano<br />
Flavia Bortolotti, Padova<br />
Giuseppe Brisinda, Rome<br />
Giovanni Cammarota, Roma<br />
Antonino Cavallari, Bologna<br />
Giuseppe Chiarioni, Valeggio<br />
Michele Cicala, Rome<br />
Amedeo Columbano, Cagliari<br />
Massimo Conio, Sanremo<br />
Dario Conte, Milano<br />
Gino Roberto Corazza, Pavia<br />
Francesco Costa, Pisa<br />
Antonio Craxi, Palermo<br />
Silvio Danese, Milan<br />
Roberto De Giorgio, Bologna<br />
Giovanni D De Palma, Naples<br />
Fabio Farinati, Padua<br />
Giammarco Fava, Ancona<br />
Francesco Feo, Sassari<br />
Stefano Fiorucci, Perugia<br />
Andrea Galli, Firenze<br />
Valeria Ghisett, Turin<br />
Gianluigi Giannelli, Bari<br />
Edoardo G Giannini, Genoa<br />
Paolo Gionchetti, Bologna<br />
Mario Guslandi, Milano<br />
Pietro Invernizzi, Milan<br />
Giacomo Laffi , Firenze<br />
Giovanni Maconi, Milan<br />
Lucia Malaguarnera, Catania<br />
ED Mangoni, Napoli<br />
Giulio Marchesini, Bologna<br />
Fabio Marra, Florence<br />
Marco Marzioni, Ancona<br />
Giuseppe Montalto, Palermo<br />
Giovanni Monteleone, Rome<br />
Giovanni Musso, Torino<br />
Gerardo Nardone, Napoli<br />
Valerio Nobili, Rome<br />
Luisi Pagliaro, Palermo<br />
Francesco Pallone, Rome<br />
Fabrizio R Parente, Milan<br />
F Perri, San Giovanni Rotondo<br />
Raffaele Pezzilli, Bologna<br />
A Pilotto, San Giovanni Rotondo<br />
Mario Pirisi, Novara<br />
Paolo Del Poggio, Treviglio<br />
Gabriele Bianchi Porro, Milano<br />
Piero Portincasa, Bari<br />
Bernardino Rampone, Siena<br />
Claudio Romano, Messina<br />
Marco Romano, Napoli<br />
Gerardo Rosati, Potenza<br />
Enrico Roda, Bologna<br />
Domenico Sansonno, Bari<br />
Vincenzo Savarino, Genova<br />
Mario Del Tacca, Pisa<br />
Giovanni Tarantino, Naples<br />
Roberto Testa, Genoa<br />
Pier Alberto Testoni, Milan<br />
Dino Vaira, Bologna<br />
Japan<br />
Kyoichi Adachi, Izumo<br />
Yasushi Adachi, Sapporo<br />
Taiji Akamatsu, Matsumoto<br />
Sk Md Fazle Akbar, Ehime<br />
Takafumi Ando, Nagoya<br />
Akira Andoh, Otsu<br />
Taku Aoki, Tokyo<br />
Masahiro Arai, Tokyo<br />
Tetsuo Arakawa, Osaka<br />
Yasuji Arase, Tokyo<br />
Masahiro Asaka, Sapporo<br />
Hitoshi Asakura, Tokyo<br />
Takeshi Azuma, Fukui<br />
Yoichi Chida, Fukuoka<br />
Takahiro Fujimori, Tochigi<br />
Jiro Fujimoto, Hyogo<br />
Kazuma Fujimoto, Saga<br />
Mitsuhiro Fujishiro, Tokyo<br />
Yoshihide Fujiyama, Otsu<br />
Hirokazu Fukui, Tochigi<br />
Hiroyuki Hanai, Hamamatsu<br />
Kazuhiro Hanazaki, Kochi<br />
Naohiko Harada, Fukuoka<br />
Makoto Hashizume, Fukuoka<br />
Tetsuo Hayakawa, Nagoya<br />
Kazuhide Higuchi, Osaka<br />
Keisuke Hino, Ube<br />
Keiji Hirata, Kitakyushu<br />
Yuji Iimuro, Nishinomiya<br />
Kenji Ikeda, Tokyo<br />
Fumio Imazeki, Chiba<br />
Yutaka Inagaki, Kanagawa<br />
Yasuhiro Inokuchi, Yokohama<br />
Haruhiro Inoue, Yokohama<br />
Masayasu Inoue, Osaka<br />
Akio Inui, Kagoshima<br />
Hiromi Ishibashi, Nagasaki<br />
Shunji Ishihara, Izumo<br />
Toru Ishikawa, Niigata<br />
Kei Ito, Sendai<br />
Masayoshi Ito, Tokyo<br />
Hiroaki Itoh, Akita<br />
Ryuichi Iwakiri, Saga<br />
Yoshiaki Iwasaki, Okayama<br />
Terumi Kamisawa, Tokyo<br />
Hiroshi Kaneko, Aichi-Gun<br />
Shuichi Kaneko, Kanazawa<br />
Takashi Kanematsu, Nagasaki<br />
Mitsuo Katano, Fukuoka<br />
Junji Kato, Sapporo<br />
Mototsugu Kato, Sapporo<br />
Shinzo Kato, Tokyo<br />
Norifumi Kawada, Osaka<br />
Sunao Kawano, Osaka<br />
Mitsuhiro Kida, Kanagawa<br />
Yoshikazu Kinoshita, Izumo<br />
Tsuneo Kitamura, Chiba<br />
Seigo Kitano, Oita<br />
Kazuhiko Koike, Tokyo<br />
Norihiro Kokudo, Tokyo<br />
Satoshi Kondo, Sapporo<br />
Shoji Kubo, Osaka<br />
Masato Kusunoki, Tsu Mie<br />
Katsunori Iijima, Sendai<br />
Shin Maeda, Tokyo<br />
Masatoshi Makuuchi, Tokyo<br />
Osamu Matsui, Kanazawa<br />
Yasuhiro Matsumura, Chiba<br />
Yasushi Matsuzaki, Tsukuba<br />
Kiyoshi Migita, Omura<br />
Tetsuya Mine, Kanagawa<br />
Hiroto Miwa, Hyogo<br />
Masashi Mizokami, Nagoya<br />
Yoshiaki Mizuguchi, Tokyo<br />
Motowo Mizuno, Hiroshima<br />
www.wjgnet.com<br />
Morito Monden, Suita<br />
Hisataka S Moriwaki, Gifu<br />
Yasuaki Motomura, Iizuka<br />
Yoshiharu Motoo, Kanazawa<br />
Kazunari Murakami, Oita<br />
Kunihiko Murase, Tusima<br />
Masahito Nagaki, Gifu<br />
Masaki Nagaya, Kawasaki<br />
Yuji Naito, Kyoto<br />
Hisato Nakajima, Tokyo<br />
Hiroki Nakamura, Yamaguchi<br />
Shotaro Nakamura, Fukuoka<br />
Mikio Nishioka, Niihama<br />
Shuji Nomoto, Nagoya<br />
Susumu Ohmada, Maebashi<br />
Masayuki Ohta, Oita<br />
Tetsuo Ohta, Kanazawa<br />
Kazuichi Okazaki, Osaka<br />
Katsuhisa Omagari, Nagasaki<br />
Saburo Onishi, Nankoku<br />
Morikazu Onji, Ehime<br />
Satoshi Osawa, Hamamatsu<br />
Masanobu Oshima, Kanazawa<br />
Hiromitsu Saisho, Chiba<br />
Hidetsugu Saito, Tokyo<br />
Yutaka Saito, Tokyo<br />
Isao Sakaida, Yamaguchi<br />
Michiie Sakamoto, Tokyo<br />
Yasushi Sano, Chiba<br />
Hiroki Sasaki, Tokyo<br />
Iwao Sasaki, Sendai<br />
Motoko Sasaki, Kanazawa<br />
Chifumi Sato, Tokyo<br />
Shuichi Seki, Osaka<br />
Hiroshi Shimada, Yokohama<br />
Mitsuo Shimada, Tokushima<br />
Tomohiko Shimatan, Hiroshima<br />
Hiroaki Shimizu, Chiba<br />
Ichiro Shimizu, Tokushima<br />
Yukihiro Shimizu, Kyoto<br />
Shinji Shimoda, Fukuoka<br />
Tooru Shimosegawa, Sendai<br />
Tadashi Shimoyama, Hirosaki<br />
Ken Shirabe, Iizuka<br />
Yoshio Shirai, Niigata<br />
Katsuya Shiraki, Mie<br />
Yasushi Shiratori, Okayama<br />
Masayuki Sho, Nara<br />
Yasuhiko Sugawara, Tokyo<br />
Hidekazu Suzuki, Tokyo<br />
Minoru Tada, Tokyo<br />
Tadatoshi Takayama, Tokyo<br />
Tadashi Takeda, Osaka<br />
Koji Takeuchi, Kyoto<br />
Kiichi Tamada, Tochigi<br />
Akira Tanaka, Kyoto<br />
Eiji Tanaka, Matsumoto<br />
Noriaki Tanaka, Okayama<br />
Shinji Tanaka, Hiroshima<br />
Wei Tang, Tokyo<br />
Hideki Taniguchi, Yokohama<br />
Kyuichi Tanikawa, Kurume<br />
Akira Terano, Shimotsugagun<br />
Hitoshi Togash, Yamagata<br />
Kazunari Tominaga, Osaka<br />
Takuji Torimura, Fukuoka<br />
Minoru Toyota, Sapporo<br />
Akihito Tsubota, Chiba<br />
Shingo Tsuji, Osaka<br />
Takato Ueno, Kurume<br />
Shinichi Wada, Tochigi<br />
Hiroyuki Watanabe, Kanazawa<br />
Toshio Watanabe, Osaka<br />
Yuji Watanabe, Ehime<br />
Chun-Yang Wen, Nagasaki<br />
Koji Yamaguchi, Fukuoka<br />
Takayuki Yamamoto, Yokkaichi<br />
Takashi Yao, Fukuoka<br />
Ⅲ
IV<br />
Masashi Yoneda, Tochigi<br />
Hiroshi Yoshida, Tokyo<br />
Masashi Yoshida, Tokyo<br />
Norimasa Yoshida, Kyoto<br />
Kentaro Yoshika, Toyoake<br />
Masahide Yoshikawa, Kashihara<br />
Lebanon<br />
Bassam N Abboud, Beirut<br />
Ala I Sharara, Beirut<br />
Joseph Daoud Boujaoude, Beirut<br />
Lithuania<br />
Limas Kupcinskas, Kaunas<br />
Macedonia<br />
Vladimir Cirko Serafi moski, Skopje<br />
Malaysia<br />
Andrew Seng Boon Chua, Ipoh<br />
Khean-Lee Goh, Kuala Lumpur<br />
Jayaram Menon, Sabah<br />
Mexico<br />
Garcia-Compean Diego, Monterrey<br />
E R Marin-Lopez, Jesús García<br />
Saúl Villa-Treviño, México<br />
JK Yamamoto-Furusho, México<br />
Monaco<br />
Patrick Rampal, Monaco<br />
Netherlands<br />
Ulrich Beuers, Amsterdam<br />
Gerd Bouma, Amsterdam<br />
Lee Bouwman, Leiden<br />
J Bart A Crusius, Amsterdam<br />
Janine K Kruit, Groningen<br />
Ernst Johan Kuipers, Rotterdam<br />
Ton Lisman, Utrecht<br />
Yi Liu, Amsterdam<br />
Servaas Morré, Amsterdam<br />
Chris JJ Mulder, Amsterdam<br />
Michael Müller, Wageningen<br />
Amado Salvador Peña, Amsterdam<br />
Robert J Porte, Groningen<br />
Ingrid B Renes, Rotterdam<br />
Andreas Smout, Utrecht<br />
RW Stockbrugger, Maastricht<br />
Luc JW van der Laan, Rotterdam<br />
Karel van Erpecum, Utrecht<br />
GP VanBerge-Henegouwen,Utrecht<br />
New Zealand<br />
Ian David Wallace, Auckland<br />
Nigeria<br />
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Norway<br />
Trond Berg, Oslo<br />
Tom Hemming Karlsen, Oslo<br />
Helge Lyder Waldum, Trondheim<br />
Pakistan<br />
Muhammad S Khokhar, Lahore<br />
Poland<br />
Tomasz Brzozowski, Cracow<br />
Robert Flisiak, Bialystok<br />
Hanna Gregorek, Warsaw<br />
DM Lebensztejn, Bialystok<br />
Wojciech G Polak, Wroclaw<br />
Marek Hartleb, Katowice<br />
Portugal<br />
MP Cecília, Lisbon<br />
Miguel Carneiro De Moura, Lisbon<br />
Russia<br />
Vladimir T Ivashkin, Moscow<br />
Leonid Lazebnik, Moscow<br />
Vasiliy I Reshetnyak, Moscow<br />
Saudi Arabia<br />
Ibrahim Abdulkarim Al M<strong>of</strong>l eh, Riyadh<br />
Serbia<br />
DM Jovanovic, Sremska Kamenica<br />
Singapore<br />
Bow Ho, Kent Ridge<br />
Khek-Yu Ho, Singapore<br />
Francis Seow-Choen, Singapore<br />
Slovakia<br />
Anton Vavrecka, Bratislava<br />
Slovenia<br />
Sasa Markovic, Ljubljana<br />
South Africa<br />
Michael C Kew, Parktown<br />
South Korea<br />
Byung Ihn Choi, Seoul<br />
Ho Soon Choi, Seoul<br />
M Yeo, Suwon<br />
Sun Pyo Hong, Gyeonggi-do<br />
Jae J Kim, Seoul<br />
Jin-Hong Kim, Suwon<br />
Myung-Hwan Kim, Seoul<br />
Chang Hong Lee, Seoul<br />
Jong Kyun Lee, Seoul<br />
Eun-Yi Moon, Seoul<br />
Jae-Gahb Park, Seoul<br />
Dong Wan Seo, Seoul<br />
Dong jin Suh, Seoul<br />
Spain<br />
Juan G Abraldes, Barcelona<br />
Agustin Albillos, Madrid<br />
Raul J Andrade, Málaga<br />
Luis Aparisi, Valencia<br />
Fernando Azpiroz, Barcelona<br />
Ramon Bataller, Barcelona<br />
Josep M Bordas, Barcelona<br />
Xavier Calvet, Sabadell<br />
Andres Cardenas, Barcelona<br />
Vicente Carreño, Madrid<br />
Jose Castellote, Barcelona<br />
Antoni Castells, Barcelona<br />
Vicente Felipo, Valencia<br />
Juan C Garcia-Pagán, Barcelona<br />
Jaime Bosch Genover, Barcelona<br />
Jaime Guardia, Barcelona<br />
Angel Lanas, Zaragoza<br />
María Isabel Torres López, Jaén<br />
José M Mato, Derio<br />
Juan F Medina, Pamplona<br />
MA Muñoz-Navas, Pamplona<br />
Julian Panes, Barcelona<br />
Miguel Minguez Perez, Valencia<br />
Miguel Perez-Mateo, Alicante<br />
Josep M Pique, Barcelona<br />
Jesús M Prieto, Pamplona<br />
Sabino Riestra, Pola De Siero<br />
Luis Rodrigo, Oviedo<br />
Manuel Romero-Gómez, Sevilla<br />
Sweden<br />
Einar Stefan Björnsson, Gothenburg<br />
Curt Einarsson, Huddinge<br />
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Ulf Hindorf, Lund<br />
Hanns-Ulrich Marschall, Stockholm<br />
Lars Christer Olbe, Molndal<br />
Matti Sallberg, Stockholm<br />
Magnus Simrén, Göteborg<br />
Xiao-Feng Sun, Linköping<br />
Ervin Tóth, Malmö<br />
Weimin Ye, Stockholm<br />
Switzerland<br />
Chrish Beglinger, Basel<br />
Pierre A Clavien, Zurich<br />
Jean-Francois Dufour, Bern<br />
Franco Fortunato, Zürich<br />
Jean Louis Frossard, Geneva<br />
Gerd A Kullak-Ublick, Zurich<br />
Pierre Michetti, Lausanne<br />
Francesco Negro, Genève<br />
Bruno Stieger, Zurich<br />
Radu Tutuian, Zurich<br />
Stephan Robert Vavricka, Zurich<br />
Arthur Zimmermann, Berne<br />
Turkey<br />
Yusuf Bayraktar, Ankara<br />
Figen Gurakan, Ankara<br />
Aydin Karabacakoglu, Konya<br />
Serdar Karakose, Konya<br />
Hizir Kurtel, Istanbu<br />
Osman Cavit Ozdogan, Istanbul<br />
Özlem Yilmaz, Izmir<br />
Cihan Yurdaydin, Ankara<br />
United Arab Emirates<br />
Sherif M Karam, Al-Ain<br />
United Kingdom<br />
David Adams, Birmingham<br />
NK Ahluwalia, Stockport<br />
CG Antoniades, London<br />
Anthony TR Axon, Leeds<br />
Qasim Aziz, Manchester<br />
Nicholas M Barnes, Birmingham<br />
Jim D Bell, London<br />
Mairi Brittan, London<br />
Alastair David Burt, Newcastle<br />
Simon Scott Campbell, Manchester<br />
Simon R Carding, Leeds<br />
Paul Jonathan Ciclitira, London<br />
Eithne Costello, Liverpool<br />
Tatjana Crnogorac-Jurcevic, London<br />
Amar Paul Dhillon, London<br />
Emad M El-Omar, Aberdeen<br />
Annette Fristscher-Ravens, London<br />
Elizabeth Furrie, Dundee<br />
Daniel Richard Gaya, Edinburgh<br />
Subrata Ghosh, London<br />
William Greenhalf, Liverpool<br />
Indra Neil Guha, Southampton<br />
Peter Clive Hayes, Edinburgh<br />
Gwo-Tzer Ho, Edinburgh<br />
Anthony R Hobson, Salford<br />
Stefan G Hübscher, Birmingham<br />
Robin Hughes, London<br />
Pali Hungin, Stockton<br />
David Paul Hurlstone, Sheffi eld<br />
Rajiv Jalan, London<br />
Janusz AZ Jankowski, Oxford<br />
Brian T Johnston, Belfast<br />
David EJ Jones, Newcastle<br />
Michael A Kamm, Harrow<br />
Peter Karayiannis, London<br />
Laurens Kruidenier, Harlow<br />
Patricia F Lalor, Birmingham<br />
Hong-Xiang Liu, Cambridge<br />
K E L McColl, Glasgow<br />
Stuart AC McDonald, London
Dermot Patrick Mcgovern, Oxford<br />
Giorgina Mieli-Vergani, London<br />
Nikolai V Naoumov, London<br />
John P Neoptolemos, Liverpool<br />
James Neuberger, Birmingham<br />
Mark S Pearce, Newcastle Upon Tyne<br />
Stephen P Pereira, London<br />
D Mark Pritchard, Liverpool<br />
Stephen E Roberts, Swansea<br />
Marco Senzolo, Padova<br />
Soraya Shirazi-Beechey, Liverpool<br />
Robert Sutton, Liverpool<br />
Simon D Taylor-Robinson, London<br />
Paris P Tekkis, London<br />
Ulrich Thalheimer, London<br />
Nick Paul Thompson, Newcastle<br />
David Tosh, Bath<br />
Frank Ivor Tovey, London<br />
Chris Tselepis, Birmingham<br />
Diego Vergani, London<br />
Ge<strong>of</strong>frey Warhurst, Salford<br />
Peter James Whorwell, Manchester<br />
Roger Williams, London<br />
Karen Leslie Wright, Bath<br />
Min Zhao, Foresterhill<br />
United States<br />
Gary A Abrams, Birmingham<br />
Golo Ahlenstiel, Bethesda<br />
BS Anand, Houston<br />
Frank A Anania, Atlanta<br />
M Ananthanarayanan, New York<br />
Gavin Edward Arteel, Louisville<br />
Jasmohan Singh Bajaj, Milwaukee<br />
Jamie S Barkin, Miami Beach<br />
Kim Elaine Barrett, San Diego<br />
Marc Basson, Detroit<br />
Wallace F Berman, Durham<br />
Timothy R Billiar, Pittsburgh<br />
Edmund J Bini, New York<br />
Jennifer D Black, Buffalo<br />
Herbert L Bonkovsky, Farmington<br />
Andrea D Branch, New York<br />
Robert S Bresalier, Houston<br />
Alan L Buchman, Chicago<br />
Alan Cahill, Philadelphia<br />
John M Carethers, San Diego<br />
David L Carr-Locke, Boston<br />
Ravi S Chari, Nashville<br />
Jiande Chen, Galveston<br />
Xian-Ming Chen, Omaha<br />
Ramsey Chi-man Cheung, Palo Alto<br />
William D Chey, Ann Arbor<br />
John Y Chiang, Rootstown<br />
Parimal Chowdhury, Arkansas<br />
Raymond T Chung, Boston<br />
James M Church, Cleveland<br />
Mark G Clemens, Charlotte<br />
Vincent Coghlan, Beaverton<br />
David Cronin II, New Haven<br />
John Cuppoletti, Cincinnati<br />
Mark James Czaja, New York<br />
Peter V Danenberg, Los Angeles<br />
Kiron Moy Das, New Brunswick<br />
Sharon DeMorrow, Temple<br />
Deborah L Diamond, Seattle<br />
Peter Draganov, Florida<br />
Bijan Eghtesad, Cleveland<br />
Hala El-Zimaity, Houston<br />
Michelle Embree-Ku, Providence<br />
Ronnie Fass, Tucson<br />
Mark A Feitelson, Philadelphia<br />
Ariel E Feldstein, Cleveland<br />
Alessandro Fichera, Chicago<br />
Chris E Forsmark, Gainesville<br />
Chandrashekhar R Gandhi, Pittsburgh<br />
Susan L Gearhart, Baltimore<br />
Xupeng Ge, Boston<br />
John P Geibel, New Haven<br />
Xin Geng, New Brunswick<br />
Jean-Francois Geschwind, Baltimore<br />
Ignacio Gil-Bazo, New York<br />
Shannon S Glaser, Temple<br />
Ajay Goel, Dallas<br />
Julia Butler Greer, Pittsburgh<br />
James Henry Grendell, New York<br />
David R Gretch, Seattle<br />
Stefano Guandalini, Chicago<br />
Anna S Gukovskaya, Los Angeles<br />
Sanjeev Gupta, Bronx<br />
David J Hackam, Pittsburgh<br />
Stephen B Hanauer, Chicago<br />
Gavin Harewood, Rochester<br />
Margaret McLean Heitkemper, Seattle<br />
Alan W Hemming, Gainesville<br />
Samuel B Ho, San Diego<br />
Colin William Howden, Chicago<br />
Hongjin Huang, Alameda<br />
Jamal A Ibdah, Columbia<br />
Atif Iqbal, Omaha<br />
Hajime Isomoto, Rochester<br />
Hartmut Jaeschke, Tucson<br />
Dennis M Jensen, Los Angeles<br />
Leonard R Johnson, Memphis<br />
Michael P Jones, Chicago<br />
Peter James Kahrilas, Chicago<br />
AN Kalloo, Baltimore<br />
Neil Kaplowitz, Los Angeles<br />
Rashmi Kaul, Tulsa<br />
Jonathan D Kaunitz, Los Angeles<br />
Ali Keshavarzian, Chicago<br />
Miran Kim, Providence<br />
Joseph B Kirsner, Chicago<br />
Leonidas G Koniaris, Miami<br />
Burton I Korelitz, New York<br />
Robert J Korst, New York<br />
Richard A Kozarek, Seattle<br />
Michael Kremer, Chapel Hill<br />
Shiu-Ming Kuo, Buffalo<br />
Daryl Tan Yeung Lau, Galvesto<br />
Joel E Lavine, San Diego<br />
Dirk J van Leeuwen, Lebanon<br />
Glen A Lehman, Indianapolis<br />
Alex B Lentsch, Cincinnati<br />
Andreas Leodolter, La Jolla<br />
Gene LeSage, Houston<br />
Ming Li, New Orleans<br />
Zhiping Li, Baltimore<br />
LM Lichtenberger, Houston<br />
GR Lichtenstein, Philadelphia<br />
Otto Schiueh-Tzang Lin, Seattle<br />
Martin Lipkin, New York<br />
Edward V L<strong>of</strong>tus, Rocheste<br />
Robin G Lorenz, Birmingham<br />
Michael Ronan Lucey, Madison<br />
JD Luketich, Pittsburgh<br />
Henry Thomson Lynch, Omaha<br />
Patrick M Lynch, Houston<br />
Peter J Mannon, Bethesda<br />
Charles Milton Mansbach, Memphis<br />
John Frank Di Mari, Texas<br />
John M Mariadason, Bronx<br />
WM Mars, Pittsburgh<br />
Laura E Matarese, Pittsburgh<br />
Lynne V McFarland, Washington<br />
Kevin McGrath, Pittsburgh<br />
Harihara Mehendale, Monroe<br />
Stephan Menne, New York<br />
Howard Mertz, Nashville<br />
George W Meyer, Sacramento<br />
G Michalopoulos, Pittsburgh<br />
James Michael Millis, Chicago<br />
Albert D Min, New York<br />
Pramod Kumar Mistry, New Haven<br />
www.wjgnet.com<br />
Smruti Ranjan Mohanty, Chicago<br />
Satdarshan Singh Monga, Pittsburgh<br />
Timothy H Moran, Baltimore<br />
Steven F Moss, Providence<br />
Masaki Nagaya, Boston<br />
Laura Eleanor Nagy, Cleveland<br />
Hiroshi Nakagawa, Philadelphia<br />
Douglas B Nelson, Minneaplis<br />
Brant K Oelschlager, Washington<br />
Curtis T Okamoto, Los Angeles<br />
Stephen JD O’Keefe, Pittsburgh<br />
Dimitry Oleynikov, Omaha<br />
Natalia A Osna, Omaha<br />
Stephen J Pandol, Los Angeles<br />
Pankaj Jay Pasricha, Gaveston<br />
Zhiheng Pei, New York<br />
Michael A Pezzone, Pittsburgh<br />
CS Pitchumoni, New Brunswiuc<br />
Jay Pravda, Gainesville<br />
M Raimondo, Jacksonville<br />
GS Raju, Galveston<br />
Murray B Resnick, Providence<br />
Adrian Reuben, Charleston<br />
Douglas K Rex, Indianapolis<br />
Victor E Reyes, Galveston<br />
Richard A Rippe, Chapel Hill<br />
Marcos Rojkind, Washington<br />
Philip Rosenthal, San Francisco<br />
Hemant Kumar Roy, Evanston<br />
Shawn David Safford, Norfolk<br />
Bruce E Sands, Boston<br />
NJ Shaheen, Chapel Hill<br />
Harvey L Sharp, Minneapolis<br />
Stuart Sherman, Indianapolis<br />
Shivendra Shukla, Columbia<br />
Alphonse E Sirica, Virginia<br />
Shanthi V Sitaraman, Atlanta<br />
Shanthi Srinivasan, Atlanta<br />
Michael Steer, Boston<br />
Gary D Stoner, Columbus<br />
Liping Su, Chicago<br />
Christina Surawicz, Seattle<br />
Gyongyi Szabo, Worcester<br />
Yvette Taché, Los Angeles<br />
Seng-Lai Tan, Seattle<br />
Andrzej Tarnawski, Long Beach<br />
Andrzej S Tarnawski, Orange<br />
K-M Tchou-Wong, New York<br />
Neil D Theise, New York<br />
PJ Thuluvath, Baltimore<br />
Swan Nio Thung, New York<br />
Natalie J Torok, Sacramento<br />
RA Travagli, Baton Rouge<br />
G Triadafi lopoulos, Stanford<br />
James F Trotter, Denver<br />
Chung-Jyi Tsai, Lexington<br />
Andrew Ukleja, Florida<br />
Hugo E Vargas, Scottsdale<br />
Scott A Waldman, Philadelphia<br />
Jian-Ying Wang, Baltimore<br />
Steven David Wexner, Weston<br />
Keith Tucker Wilson, Baltimore<br />
Jacqueline L Wolf, Boston<br />
Jackie Wood, Ohio<br />
George Y Wu, Farmington<br />
Jian Wu, Sacramento<br />
Samuel Wyllie, Houston<br />
Wen Xie, Pittsburgh<br />
Yoshio Yamaoka, Houston<br />
Vincent W Yang, Atlanta<br />
Francis Y Yao, San Francisco<br />
Min You, Tampa<br />
Zobair M Younossi, Virginia<br />
Liqing Yu, Winston-Salem<br />
David Yule, Rochester<br />
Ruben Zamora, Pittsburgh<br />
Michael E Zenilman, New York<br />
Zhi Zhong, Chapel Hill<br />
Uruguay<br />
Henry Cohen, Montevideo<br />
Ⅴ
�ational <strong>Journal</strong> Award<br />
2005<br />
Contents<br />
EDITORIAL<br />
REVIEW<br />
TOPIC HIGHTLIGHTS<br />
GASTRIC CANCER<br />
CLINICAL RESEARCH<br />
RAPID COMMUNICATION<br />
<strong>World</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Gastroenterology</strong> ®<br />
Volume 13 Number <strong>18</strong><br />
May 14, 2007<br />
2523 Magnifying chromoscopy, a novel and useful technique for colonoscopy in<br />
ulcerative colitis<br />
Ando T, Takahashi H, Watanabe O, Maeda O, Ishiguro K, Ishikawa D, Hasegawa M, Ohmiya N,<br />
Niwa Y, Goto H<br />
2529 Magnetic resonance cholangiopancreatography: A useful tool in the evaluation <strong>of</strong><br />
pancreatic and biliary disorders<br />
Halefoglu AM<br />
2535 Portal hypertension due to portal venous thrombosis: Etiology, clinical<br />
outcomes<br />
Harmanci O, Bayraktar Y<br />
2541 �lycogen �lycogen storage diseases: �ew �ew perspectives<br />
Özen H<br />
2554 �uture �uture prospectives for the management <strong>of</strong> chronic hepatitis ��<br />
Leemans WF, Janssen HLA, de Man RA<br />
2568 Promoter Promoter hypermethylation <strong>of</strong><br />
<strong>of</strong> CDH1, �HIT, MTAP and PLA�L1 in gastric<br />
adenocarcinoma in individuals from �orthern �razil<br />
Leal MF, Lima EM, Silva PNO, Assumpção PP, Calcagno DQ, Payão SLM,<br />
Burbano RR, de Arruda Cardoso Smith M<br />
2575 A preliminary study <strong>of</strong> neck-stomach syndrome<br />
Song XH, Xu XX, Ding LW, Cao L, Sadel A, Wen H<br />
2581 H pylori iceA alleles are disease-specific virulence factors<br />
Caner V, Yilmaz M, Yonetci N, Zencir S, Karagenc N, Kaleli I, Bagci H<br />
2586 Long-term results <strong>of</strong> endosurgical and open surgical approach for Zenker<br />
diverticulum<br />
Bonavina L, Bona D, Abraham M, Saino G, Abate E<br />
2590 Long-term results <strong>of</strong> subtotal colectomy with cecorectal anastomosis for<br />
isolated colonic inertia<br />
Iannelli A, Piche T, Dainese R, Fabiani P, Tran A, Mouiel J, Gugenheim J<br />
2596 Effects <strong>of</strong> granulocyte-colony stimulating factor on peritoneal defense<br />
mechanisms and bacterial translocation after administration <strong>of</strong> systemic<br />
chemotherapy in rats<br />
Cerci C, Ergin C, Eroglu E, Agalar C, Agalar F, Cerci S, Bulbul M<br />
2600 Study <strong>of</strong> the duodenal contractile activity during antral contractions<br />
Shafik A, El Sibai O, Shafik AA<br />
2604 Clinical presentation and genotype <strong>of</strong> hepatitis delta in Karachi<br />
Moatter T, Abbas Z, Shabir S, Jafri W<br />
www.wjgnet.com<br />
The WJ� Press
Contents<br />
RAPID COMMUNICATION<br />
CASE REPORT<br />
LETTERS TO THE EDITOR<br />
ACKNOWLEDGMENTS<br />
APPENDIX<br />
FLYLEAF<br />
INSIDE FRONT COVER<br />
INSIDE BACK COVER<br />
2608 Protein pr<strong>of</strong>ile <strong>of</strong> human hepatocarcinoma cell line SMMC-7721:<br />
Identification and functional analysis<br />
Feng Y, Tian ZM, Wan MX, Zheng ZB<br />
2615 Pancreas duodenal homeobox-1 expression and significance in pancreatic<br />
cancer<br />
Liu T, Gou SM, Wang CY, Wu HS, Xiong JX, Zhou F<br />
2619 Surgical management <strong>of</strong> 143 patients with adult primary retroperitoneal<br />
tumor<br />
Xu YH, Guo KJ, Guo RX, Ge CL, Tian YL, He SG<br />
2622 Expression level <strong>of</strong> beta-catenin is associated with prognosis <strong>of</strong> esophageal<br />
carcinoma<br />
Ji L, Cao XF, Wang HM, Li YS, Zhu B, Xiao J, Wang D<br />
2626 Study <strong>of</strong> the expressions <strong>of</strong> p 53 and bcl -2 genes, the telomerase activity and<br />
apoptosis in �IST patients<br />
Wang Q, Kou YW<br />
2629 Effect <strong>of</strong> sunitinib on metastatic gastrointestinal stromal tumor in patients<br />
with neur<strong>of</strong>ibromatosis type 1: A case report<br />
Kalender ME, Sevinc A, Tutar E, Sirikci A, Camci C<br />
2633 Ectopic fascioliasis mimicking a colon tumor<br />
Makay O, Gurcu B, Caliskan C, Nart D, Tuncyurek M, Korkut M<br />
2636 Celiac disease manifested by polyneuropathy and swollen ankle<br />
Djuric Z, Kamenov B, Katic V<br />
2639 Therapeutic strategies for pediatric non-alcoholic fatty liver disease: A<br />
challenge for health care providers<br />
Nobili V, Manco M<br />
2642 Insulin and heparin in treatment <strong>of</strong> hypertriglyceridemia-induced pancreatitis<br />
Jain P, Rai RR, Udawat H, Nijhawan S, Mathur A<br />
2644 Acknowledgments to Reviewers <strong>of</strong> <strong>World</strong> <strong>Journal</strong> <strong>of</strong> �astroenterology<br />
2645 Meetings<br />
2646 Instructions to authors<br />
I-V Editorial �oard<br />
Online Submissions<br />
International Subscription<br />
www.wjgnet.com<br />
<strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong><br />
Volume 13 Number <strong>18</strong> May 14, 2007
Contents<br />
Responsible E�E�ito�� E�E�ito�� �o�� �o�� t�is t�is t�is iss�e iss�e iss�e: Yong Liu<br />
C�E�ito�� �o�� t�is t�is iss�e: iss�e: Richard Rippe, PhD<br />
Responsible S�E�ito�� �o�� t�is iss�e: Ye Liu<br />
HO�ORARY EDITORS-I�-CHIE�<br />
Ke-Ji Chen, Beijing<br />
Li-Fang Chou, Taipei<br />
Zhi-Qiang Huang, Beijing<br />
Shinn-Jang Hwang, Taipei<br />
Min-Liang Kuo, Taipei<br />
Nicholas F LaRusso, Rochester<br />
Jie-Shou Li, Nanjing<br />
Geng-Tao Liu, Beijing<br />
Lein-Ray Mo, Tainan<br />
Fa-Zu Qiu, Wuhan<br />
Eamonn M Quigley, Cork<br />
David S Rampton, London<br />
Rudi Schmid, kentfield<br />
Nicholas J Talley, Rochester<br />
Guido NJ Tytgat, Amsterdam<br />
H-P Wang, Taipei<br />
Jaw-Ching Wu, Taipei<br />
Meng-Chao Wu, Shanghai<br />
Ming-Shiang Wu, Taipei<br />
Jia-Yu Xu, Shanghai<br />
Ta-Sen Yeh, Taoyuan<br />
PRESIDE�T A�D EDITOR-I�-<br />
CHIE�<br />
Lian-Sheng Ma, Beijing<br />
EDITOR-I�-CHIE�<br />
Bo-Rong Pan, Xi'an<br />
ASSOCIATE EDITORS-I�-CHIE�<br />
Gianfranco D Alpini, Temple<br />
Bruno Annibale, Roma<br />
Roger William Chapman, Oxford<br />
Chi-Hin Cho, Hong Kong<br />
Alexander L Gerbes, Munich<br />
Shou-Dong Lee, Taipei<br />
Walter Edwin Longo, New Haven<br />
You-Yong Lu, Beijing<br />
Masao Omata, Tokyo<br />
Harry HX Xia, Hanover<br />
SCIE�CE EDITORS<br />
Director: Jing Wang, Beijing<br />
Deputy Director: Jian-Zhong Zhang, Beijing<br />
MEM�ERS<br />
Ye Liu, Beijing<br />
Xing-Xia Yang, Beijing<br />
LA��UA�E EDITORS<br />
Director: Jing-Yun Ma, Beijing<br />
Deputy Director: Xian-Lin Wang, Beijing<br />
MEM�ERS<br />
Gianfranco D Alpini, Temple<br />
BS Anand, Houston<br />
Richard B Banati, Lidcombe<br />
Giuseppe Chiarioni, Valeggio<br />
John Frank Di Mari, Texas<br />
Shannon S Glaser, Temple<br />
Mario Guslandi, Milano<br />
Martin Hennenberg, Bonn<br />
Atif Iqbal, Omaha<br />
Manoj Kumar, Nepal<br />
Patricia F Lalor, Birmingham<br />
Ming Li, New Orleans<br />
Margaret Lutze, Chicago<br />
Jing-Yun Ma, Beijing<br />
Daniel Markovich, Brisbane<br />
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<strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong><br />
Volume 13 Number <strong>18</strong> May 14, 2007<br />
<strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ( <strong>World</strong> J Gastroenterol , WJG ), a leading international journal in gastroenterology and hepatology, has an established reputation<br />
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PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2523-2528<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Magnifying chromoscopy, a novel and useful technique for<br />
colonoscopy in ulcerative colitis<br />
Takafumi Ando, Hironao Takahashi, Osamu Watanabe, Osamu Maeda, Kazuhiro Ishiguro, Daisuke Ishikawa,<br />
Mot<strong>of</strong>usa Hasegawa, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto<br />
Takafumi Ando, Hironao Takahashi, Osamu Watanabe,<br />
Osamu Maeda, Kazuhiro Ishiguro, Daisuke Ishikawa,<br />
Mot<strong>of</strong>usa Hasegawa, Naoki Ohmiya, Yasumasa Niwa, Hidemi<br />
Goto, Department <strong>of</strong> <strong>Gastroenterology</strong>, Nagoya University<br />
Graduate School <strong>of</strong> Medicine, Nagoya, Japan<br />
Correspondence to: Dr. Takafumi Ando, Department <strong>of</strong><br />
<strong>Gastroenterology</strong>, Nagoya University Graduate School <strong>of</strong><br />
Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550<br />
Japan. takafumia-gi@umin.ac.jp<br />
Telephone: +81-52-7442144 Fax: +81-52-7442175<br />
Received: 2007-04-11 Accepted: 2007-04-30<br />
Abstract<br />
Ulcerative colitis (UC) is a chronic inflammatory bowel<br />
disorder characterized by exacerbations and remissions.<br />
The degree <strong>of</strong> inflammation as assessed by conventional<br />
colonoscopy is a reliable parameter <strong>of</strong> disease activity.<br />
However, even when conventional colonoscopy suggests<br />
remission and normal mucosal findings, microscopic<br />
abnormalities may persist, and relapse may occur<br />
later. Patients with long-standing, extensive ulcerative<br />
colitis have an increased risk <strong>of</strong> developing colorectal<br />
cancer. Ulcerative colitis-associated colorectal cancer<br />
is characterized by an early age at onset, poorly<br />
differentiated tumor cells, mucinous carcinoma, and<br />
multiple lesions. Early detection <strong>of</strong> dysplasia and colitic<br />
cancer is thus a prerequisite for survival. A relatively<br />
new method, magnifying chromoscopy, is thought to be<br />
useful for the early detection and diagnosis <strong>of</strong> dysplasia<br />
and colitic cancer, as well as the prediction <strong>of</strong> relapse.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Ulcerative colitis; Histopathology; Conventional<br />
colonoscopy; Magnifying colonoscopy; Ulcerative colitisassociated<br />
colorectal cancer<br />
Ando T, Takahashi H, Watanabe O, Maeda O, Ishiguro<br />
K, Ishikawa D, Hasegawa M, Ohmiya N, Niwa Y, Goto H.<br />
Magnifying chromoscopy, a novel and useful technique<br />
for colonoscopy in ulcerative colitis. <strong>World</strong> J Gastroenterol<br />
2007; 13(<strong>18</strong>): 2523-2528<br />
http://www.wjgnet.com/1007-9327/13/2523.asp<br />
INTRODUCTION<br />
The degree <strong>of</strong> inflammation in �l�erati�e �l�erati�e l�erati�e ati�e ti�e �oliti�� �oliti�� �oliti�� �oliti�� �oliti�� ����� ����� ����� ����� ����� �����<br />
EDITORIAL<br />
a�� a����e����ed by �on�entional �olono���opy i�� a reliable<br />
parameter <strong>of</strong> di��ea��e a�ti�ity.� ��en ��en �en �hen �hen �hen �on�entional<br />
�on�entional<br />
�on�entional<br />
�olono���opy ���gge��t�� remi����ion and normal m��o��al<br />
finding���� ���� �� ho�e�er�� ho�e�er�� ho�e�er�� ho�e�er�� mi�ro���opi� mi�ro���opi� mi�ro���opi� mi�ro���opi� mi�ro���opi� abnormalitie�� abnormalitie�� abnormalitie�� abnormalitie�� abnormalitie�� abnormalitie�� may<br />
may<br />
may<br />
per��i��t [����� �������� and relap��e may o���r later [�� ��� .� �� �� i�� i�� i�� a �hroni� �hroni� �hroni�<br />
di��ea��e �ith an �nkno�n �a���e �hara�teri�ed �hara�teri�ed by diff���e diff���e diff���e<br />
m��o��al inflammation <strong>of</strong> the �olore�t�m and a �o�r��e �o�r��e<br />
<strong>of</strong> e�a�erbation�� e�a�erbation�� and remi����ion�� remi����ion�� [���� ����� .� The he p�rpo��e p�rpo��e p�rpo��e <strong>of</strong><br />
treatment in patient�� patient�� patient�� �ith �ith �ith �� �� �� �� i�� i�� i�� i�� i�� th��� th��� th��� th��� th��� th��� the the a�hie�ement a�hie�ement a�hie�ement a�hie�ement a�hie�ement a�hie�ement <strong>of</strong><br />
<strong>of</strong><br />
remi����ion and maintenan�e enan�e <strong>of</strong> ��ie���en�e.� ��ie���en�e.� ��ie���en�e.� �n �n �n �n important<br />
fa�tor in �hoo��ing treatment method�� i�� the e�al�ation e�al�ation ion<br />
<strong>of</strong> di��ea��e di��ea��e a�ti�ity�� a�ti�ity���� thi�� thi�� thi�� thi�� thi�� i�� i�� i�� i�� i�� �ommonly �ommonly �ommonly �ommonly �ommonly done done ���ing ���ing ���ing ���ing ���ing �lini�al �lini�al �lini�al �lini�al �lini�al �lini�al<br />
�riteria ba��ed on ��ymptom�� [9�� o�ing o�ing to it�� it�� �on�enien�e<br />
�on�enien�e<br />
�on�enien�e �e<br />
and nonin�a��i�ene����.� ne����.� .� �hen �hen �hen �hen hen �lini�al �lini�al �lini�al �lini�al �lini�al �riteria �riteria �riteria �riteria �riteria are are ���ed ���ed ���ed ���ed ���ed<br />
alone�� �� ho�e�er�� ho�e�er�� ho�e�er�� ho�e�er�� ���� ���� ���� ���� ���� <strong>of</strong> <strong>of</strong> patient�� patient�� patient�� patient�� patient�� in in �hom �hom �hom �hom �hom remi����ion remi����ion remi����ion remi����ion remi����ion i�� i�� i�� i�� i��<br />
a�hie�ed relap��e �ithin � year [������� �������� .� ����� ����� �������� �������� ���������� ����������<br />
the need for �olono���opi� �olono���opi� and hi��topathologi� hi��topathologi� a����e����ment a����e����ment<br />
al��o���� not�ith��tanding not�ith��tanding not�ith��tanding not�ith��tanding their their di��ad�antage���� di��ad�antage���� di��ad�antage���� di��ad�antage���� di��ad�antage���� �� in�l�ding in�l�ding in�l�ding in�l�ding in�l�ding in�l�ding in�l�ding in�l�ding<br />
in�on�enien�e�� in�a��i�ene���� and prolongation <strong>of</strong> the<br />
�olono���opi� e�amination.�<br />
Patient�� �ith long���tanding �� �� are kno�n kno�n kno�n to ha�e ha�e ha�e an<br />
in�rea��ed ri��k for the de�elopment <strong>of</strong> �olore�tal �an�er.�<br />
�ltho�gh ��ome in�e��tigator�� in�e��tigator�� re�ommend re�ommend re�ommend prophyla�ti� prophyla�ti� prophyla�ti� prophyla�ti� �ti� total<br />
total<br />
pro�to�ole�tomy for the��e high�ri��k patient���� ���r�eillan�e ���r�eillan�e<br />
�olono���opy to dete�t ���a����o�iated �olore�tal �an�er<br />
i�� generally performed in��tead.� �ltho�gh �ltho�gh ���a����o�iated<br />
���a����o�iated<br />
���a����o�iated<br />
dy��pla��ia i�� i�� �on��idered �on��idered �on��idered a ���ef�l ���ef�l ���ef�l marker <strong>of</strong> <strong>of</strong> �olore�tal �olore�tal �olore�tal �olore�tal �olore�tal �an�er �an�er �an�er �an�er �an�er<br />
at ���r�eillan�e �olono���opy�� re�ognition re�ognition <strong>of</strong> dy��pla��ia�� dy��pla��ia��<br />
p�r���ul�rly� ���� ���� �y���pl������� �y���pl������� �� ��� ��� ��� ���p�r�� ���p�r�� ���p�r�� �y� �y� �y� ��� ��� ��� �������������<br />
��������������<br />
�������������<br />
�������������<br />
ind��ed gran�lar gran�lar �hange�� �hange�� �hi�h �hi�h �hi�h ari��e ari��e ari��e in ba�kgro�nd ba�kgro�nd ba�kgro�nd ba�kgro�nd<br />
m��o��a.� �t �t t i�� i�� i�� therefore therefore generally generally re�ommended re�ommended re�ommended re�ommended re�ommended that<br />
that<br />
that<br />
biop��y ��pe�imen�� be taken e�ery e�ery e�ery �� �� �� �m �m �m �m �m along along the the �hole �hole �hole �hole �hole �hole �hole<br />
�olore�t�m [��� ���� .� ��en ��en �ith �ith thi�� thi�� thi�� thi�� �o�erage�� �o�erage�� �o�erage�� �o�erage�� ho�e�er�� ho�e�er�� ho�e�er�� ho�e�er�� o�e�er���� a a ��et ��et ��et ��et ��et ��et ��et<br />
<strong>of</strong> �� biop��y ��pe�imen�� ha�� ha�� been theoreti�ally theoreti�ally theoreti�ally �al��lated �al��lated �al��lated<br />
to repre��ent repre��ent only �.����� �.����� �.����� <strong>of</strong> <strong>of</strong> the the total total ���rfa�e ���rfa�e ���rfa�e area area <strong>of</strong> <strong>of</strong> the<br />
the<br />
�hole �olore�t�m [��� ���� .�<br />
Of intere��t���� re�ent re�ent re�ent report�� report�� report�� ha�e ha�e ha�e indi�ated indi�ated indi�ated that that �aref�l �aref�l �aref�l �aref�l<br />
m��o��al e�amination aided by �hromoendo���opy and<br />
magnifying endo���opy�� �� and target biop��ie�� biop��ie�� biop��ie�� <strong>of</strong> �����pi�io��� �����pi�io��� �����pi�io���<br />
le��ion�� might pro�ide pro�ide more more effe�ti�e effe�ti�e effe�ti�e ���r�eillan�e ���r�eillan�e ���r�eillan�e ���r�eillan�e than than the<br />
the<br />
the<br />
taking <strong>of</strong> m�ltiple m�ltiple m�ltiple non�targeted non�targeted non�targeted biop��ie�� biop��ie�� biop��ie�� [������ ������ .�<br />
EVALUATION OF ULCERATIVE COLITIS<br />
Histopathologic assessment <strong>of</strong> UC<br />
Se�erity e�erity in �l�erati�e �l�erati�e �l�erati�e �oliti�� �oliti�� �oliti�� �oliti�� i�� i�� i�� i�� generally generally a����e����ed a����e����ed a����e����ed a����e����ed ���ing ���ing ���ing ���ing<br />
��ymptom���� laboratory data [��� ��� ���� ��l�������p�� ���������� [��������� ��������� ����� ���� ��<br />
and the hi��tologi� hi��tologi� hi��tologi� degree <strong>of</strong> inflammation in the biop��y biop��y biop��y<br />
��pe�imen�� [�������9� �������9� ���9� �9� 9� .� Of the��e�� the��e�� hi��topathologi� hi��topathologi� i��topathologi� ologi� logi� a����e����ment a����e����ment a����e����ment a����e����ment a����e����ment<br />
www.wjgnet.com
2524 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
i�� �on��idered the ��tandard for e�al�ation <strong>of</strong> di��ea��e<br />
a�ti�ity [��� ��� .� Ob��er�ation Ob��er�ation b��er�ation �nder �nder �nder �on�entional �on�entional �on�entional �olono���opy<br />
�olono���opy<br />
�olono���opy<br />
i�� regarded a�� a�� ���ef�l ���ef�l for the e�al�ation e�al�ation <strong>of</strong> di��ea��e di��ea��e a�ti�ity�� a�ti�ity��<br />
��in�e it <strong>of</strong>fer�� dire�t ob��er�ation <strong>of</strong> m��o��al �hange����<br />
b�t it remain�� �ontro�er��ial �hether �olono���opi�<br />
grade �orrelate�� �ith hi��topathlogi� finding��.� .� �otably�� �otably��<br />
the degree <strong>of</strong> hi��tologi� inflammation �ithin biop��y<br />
��pe�imen�� doe�� oe�� not ne�e����arily ne�e����arily ne�e����arily �orrelate �orrelate �orrelate �ith �ith �ith endo���opi� endo���opi� endo���opi�<br />
abnormalitie�� [����������������� ����������������� ���������� ��������� ������ ����� ��� .�<br />
Are magnifying chromoscopic findings useful for the<br />
evaluation <strong>of</strong> UC ?<br />
Mat���moto et al reported the ���ef�lne���� ���ef�lne���� ���ef�lne���� <strong>of</strong> <strong>of</strong> magnifying<br />
magnifying<br />
�hromo���opy in the a����e����ment a����e����ment a����e����ment <strong>of</strong> ��e�erity ��e�erity ��e�erity [��� ��� .� Magnifying<br />
agnifying<br />
�olono���opy �a�� performed in �� patient�� �ith �l�erati�e �l�erati�e<br />
�oliti���� �ith �ith finding�� finding�� finding�� in in the the re�t�m re�t�m re�t�m graded graded a��ording a��ording a��ording to<br />
to<br />
net�ork pattern ���P�� ���P�� ���P�� and �ryptal �ryptal �ryptal opening ��O��.� ��O��.� ��O��.� ��O��.� ��O��.� The<br />
The<br />
The<br />
�lini�al�� endo���opi� and hi��tologi� grade�� <strong>of</strong> a�ti�ity did<br />
not differ bet�een gro�p�� �ategori�ed �ategori�ed by the pre��en�e pre��en�e pre��en�e or<br />
�������� �f ���� ��������.� ������r�� ������r�� ������r�� ���� ���� ���� ��� ��� ��� ��� ��� ��� f���ur��� f���ur��� f���ur���<br />
�ere �o�pled�� patient�� �ith both �i��ible �i��ible �i��ible ��P ��P ��P and and �O �O �O had<br />
had<br />
a lo�er �lini�al a�ti�ity inde� and lo�er grade <strong>of</strong> hi��tologi�<br />
������������ ���� ������ �� ���� ������r ������r �������� �������� �������� ���� ���� �a�� ���� ��een.� �����.� �����.� ��een.�.� ��een.� �����.�<br />
F�rther���� the the pre��en�e pre��en�e pre��en�e <strong>of</strong> brea�he�� brea�he�� brea�he�� ea�he�� �he�� in in ���rfa�e ���rfa�e ���rfa�e ���rfa�e ���rfa�e epitheli�m epitheli�m epitheli�m epitheli�m epitheli�m<br />
may be an additional fa�tor fa�tor in f�t�re f�t�re f�t�re relap��e relap��e relap��e [�� ����� and an<br />
�l��r�� p����r� ��� ������� �y� ���������� ��l�������p�� ������<br />
may be predi�ti�e <strong>of</strong> �o�r��e [��� ��� .�<br />
F�jiya et al propo��ed a �la����ifi�ation �la����ifi�ation �la����ifi�ation ��y��tem ��y��tem ��y��tem ��y��tem for<br />
for<br />
magnifying �olono���opi� finding�� in patient�� �ith �� ��<br />
�hi�h ha�� ha�� pro�ed pro�ed ���ef�l ���ef�l ���ef�l for the e�al�ation e�al�ation e�al�ation <strong>of</strong> di��ea��e di��ea��e di��ea��e<br />
a�ti�ity and predi�tion <strong>of</strong> period�� <strong>of</strong> remi����ion [��� .� Thi�� Thi��<br />
�l�������������� r�f�r������ referen�e�� r���ul�rly� reg�larly reg�larly �rr������ arranged �ry�p� �rypt �rypt �p���������� opening���� opening���� ������<br />
a �illo����like �illo����like appearan�e�� appearan�e�� min�te min�te defe�t�� defe�t�� <strong>of</strong> epitheli�m epitheli�m<br />
�MD������� ��mall ��mall yello�i��h yello�i��h yello�i��h ��pot�� ��pot�� ��pot�� ��pot�� �S�S���� �S�S���� �S�S���� �S�S���� �S�S���� �� and and a a �oral �oral �oral �oral �oral �oral �oral �oral reef� reef� reef� reef� reef� reef� reef� reef�<br />
like appearan�e.� �olono���opi� �olono���opi� olono���opi� finding�� finding�� finding�� �nder �nder �nder �nder thi�� thi�� thi�� thi��<br />
�l�������������� ��r� ���p�r�� ���� ������p����l����� ����������<br />
�� 61 p�������� ��� ��� u���ful������ �f ��� �l�������������� f�r<br />
predi�ting relap��e �a�� pro��pe�ti�ely analy�ed in ��.� �nder �nder �nder<br />
�on�entional �olono���opi� e�amination�� all area�� e�al�ated<br />
a�� Matt������ grade grade �� � had a �orre��ponding �orre��ponding �orre��ponding hi��topathologi�<br />
hi��topathologi�<br />
hi��topathologi�<br />
grade <strong>of</strong> �.� �n �n �n �ontra��t�� �ontra��t�� �ontra��t�� mo��t mo��t mo��t area�� area�� area�� a����e����ed a����e����ed a����e����ed a�� a�� a�� Matt���� Matt���� Matt���� �� grade<br />
grade<br />
� or � �ere diagno��ed a�� hi��topathologi� grade � or higher.�<br />
�n �ontra��t���� Matt���� Matt���� �� grade grade � �� � m��o��a m��o��a m��o��a m��o��a had had hi��topathologi�<br />
hi��topathologi�<br />
hi��topathologi�<br />
hi��topathologi�<br />
���������� ���� ��r��� fr�� qu�������� �� ������ ���������.� ������ The��e The��e<br />
re���lt�� ���gge��t ���gge��t that �hile �hile �hile normal and di��ea��ed di��ea��ed di��ea��ed di��ea��ed m��o��a m��o��a m��o��a m��o��a are<br />
ea��ily re�ogni�ed by �on�entional �olono���opy�� a����e����ment ment<br />
<strong>of</strong> the min�te min�te m��o��al m��o��al �hange�� �hange�� that refle�t refle�t ��moldering ��moldering<br />
������p����l����� ������������ ��� i�� �u�� m��h l����� le���� ��u�������ful �����e����f�l [��������� ��������� �� .�<br />
�nder nder magnifying �olono���opi� �olono���opi� e�amination�� e�amination�� in in �ontra��t�� �ontra��t�� �ontra��t��<br />
�� ���.������ ���.������ ���.������ <strong>of</strong> <strong>of</strong> the the �� �� �� area�� area�� area�� in in �hi�h �hi�h �hi�h reg�larly reg�larly reg�larly arranged<br />
arranged<br />
�rypt opening�� or a �illo����like appearan�e appearan�e �a�� �a�� �a�� dete�ted dete�ted dete�ted<br />
had a �orre��ponding hi��topathologi� grade <strong>of</strong> ��� �hile �hile all<br />
area�� �ith �ith MD��� MD��� MD��� S�S�� S�S�� S�S�� or the �oral �oral �oral reef�like reef�like reef�like appearan�e appearan�e appearan�e<br />
had a �orre��ponding hi��topathologi� grade <strong>of</strong> �� � or higher.� higher.� higher.�<br />
�n parti��lar�� �� the �orrelation �orrelation bet�een bet�een hi��topathologi�<br />
hi��topathologi�<br />
grade and magnifying �olono���opi� finding�� ���r<br />
� = �.������<br />
�a�� better than that for hi��topathologi� grade �er�����<br />
�on�entional �olono���opy ��r � � = �.������.� Thi�� Thi�� Thi�� ��t�dy ��t�dy ��t�dy fo�nd fo�nd fo�nd<br />
that patient�� in �hom MD� �a�� ob��er�ed d�ring �lini�al<br />
remi����ion fre��ently e�perien�ed e�perien�ed relap��e relap��e relap��e �ithin �ithin �ithin ��hort ��hort ��hort<br />
p�r����� �6 �6 �6 ���� ���� ���� ���p�r�� ���p�r�� ���p�r�� ���� ���� ���� ������ ������ ������ ������ �����u� �����u� �����u� �����u� �����u� ����� ����� ����� ����� ����� ���������� ���������� ���������� ���������� ����������<br />
www.wjgnet.com<br />
A B<br />
C D<br />
Figure 1 Grading <strong>of</strong> pit structures in the colorectal mucosa <strong>of</strong> patients with<br />
inactive UC.MCS grade 1: Pits are small, round, and regularly arranged (A). MCS<br />
grade 2: Pits are rather large, oval, and somewhat irregular in arrangement (B).<br />
MCS grade 3: Pits are <strong>of</strong> various shapes and sizes, and irregularly arranged (C).<br />
MCS grade 4: Dispersed pits vary in morphology and are associated with the<br />
presence <strong>of</strong> small erosions (D).<br />
and that ���� ���� ���� <strong>of</strong> patient�� patient�� patient�� �ho �ho �ho �nder�ent �nder�ent �nder�ent �lini�al �lini�al �lini�al remi����ion remi����ion remi����ion<br />
����ll ��� ������ �������� �u����� ���� MDE [��� .� Thi�� latter<br />
finding �orrelate�� �orrelate�� �ith �ith a pre�io��� pre�io��� pre�io��� pre�io��� finding finding finding that that that ���� ���� ���� ���� ���� ���� ���� ���� to<br />
to<br />
to<br />
to<br />
���� <strong>of</strong> patient�� in remi����ion a�� determined by �lini�al<br />
��ymptom�� �ere ��till in the a�ti�e a�ti�e ��tage ��tage ��tage <strong>of</strong> �l�erati�e �l�erati�e �l�erati�e �l�erati�e �oliti�� �oliti�� �oliti�� �oliti�� �oliti��<br />
������ �� ������p����l����� ���������� [������� ������� ������ ����� ��� .�<br />
Magnifying chromoscopic findings and prediction <strong>of</strong><br />
relapse<br />
�i��hio et al [��� ��� reported that magnifying��olono���opy<br />
magnifying��olono���opy<br />
magnifying��olono���opy<br />
�olono���opy<br />
�M�S�� grade �a�� a����o�iated �ith the degree <strong>of</strong> hi��tologi�al<br />
inflammation and m��o��al �L�� a�ti�ity in ��ie���ent<br />
patient�� �ith �l�erati�e �l�erati�e �oliti���� �oliti���� �oliti���� and and might might predi�t predi�t predi�t the<br />
the<br />
probability <strong>of</strong> ���b��e��ent di��ea��e relap��e in patient�� �ith<br />
�l�erati�e �oliti�� �oliti�� in remi����ion.� remi����ion.� Magnifying �olono���opy<br />
�olono���opy<br />
�olono���opy<br />
�olono���opy<br />
�a�� performed in ��� patient�� in remi����ion�� �� and the he<br />
relation��hip bet�een pit pattern���� �L�� a�ti�ity�� and<br />
hi��tologi�al di��ea��e a�ti�ity �a�� e�al�ated.� Pit pattern�� pattern�� pattern�� in<br />
��� r����l �u����� ��r� �l���������� ���� f�ur MCS ��r����� ��<br />
the ba��i�� <strong>of</strong> ��i�e�� ��hape�� and arrangement �Fig�re �Fig�re Fig�re ���.� ���.� ���.� ��.� .� The<br />
The<br />
The<br />
patient�� �ere then follo�ed follo�ed follo�ed �ntil �ntil �ntil relap��e relap��e relap��e or for a ma�im�m ma�im�m ma�im�m ma�im�m ma�im�m<br />
<strong>of</strong> �� mo.� �e���lt�� �e���lt�� ��ho�ed ��ho�ed a po��iti�e po��iti�e po��iti�e �orrelation �orrelation �orrelation bet�een bet�een bet�een<br />
M�S grade�� hi��tologi�al grade�� and m��o��al �L�� a�ti�ity.�<br />
M�lti�ariate proportional ha�ard model analy��i�� ��ho�ed<br />
that M�S grade �a�� a ��ignifi�ant predi�tor <strong>of</strong> relap��e.�<br />
Moreo�er�� the �aplan�Meier �aplan�Meier e��timate e��timate e��timate <strong>of</strong> <strong>of</strong> relap��e relap��e relap��e relap��e d�ring d�ring d�ring d�ring<br />
�� mo follo���p �a�� fo�nd to in�rea��e �ith in�rea��ing<br />
M�S grade�� �ith per�entage�� �� <strong>of</strong> ��� ��� ��� for grade ��� ��� ��� ���� ���� ���� for<br />
grade ��� ���� for grade ��� and ���� for grade �.� �ltho�gh �ltho�gh �ltho�gh<br />
M�S grade po��iti�ely �orrelated �ith hi��tologi�al grade<br />
and m��o��al �L�� a�ti�ity�� the��e latter parameter�� �ere<br />
le���� a���rate predi�tor�� <strong>of</strong> relap��e.� One rea��on rea��on rea��on may be<br />
that they are a����e����ed in biop��y ��pe�imen�� deri�ed from<br />
� ��p������ ��� l������ �r�� �f <strong>of</strong> ��l�r����l �olore�tal �olore�tal �u������� m��o��a�� m��o��a�� ���r���� �herea�� �herea��<br />
magnifying �olono���opy allo��� the ob��er�ation <strong>of</strong> a more<br />
e�tended ed and repre��entati�e repre��entati�e repre��entati�e area�� area�� area�� and and a��ordingly a��ordingly a��ordingly a��ordingly greater<br />
greater<br />
a���ra�y by M�S grading [��� .� The��e The��e finding�� finding�� demon��trate demon��trate<br />
the ���ef�lne���� <strong>of</strong> M�S M�S in the e�al�ation e�al�ation e�al�ation e�al�ation <strong>of</strong> di��ea��e di��ea��e di��ea��e di��ea��e a�ti�ity a�ti�ity a�ti�ity a�ti�ity<br />
and in predi�ting predi�ting predi�ting relap��e relap��e relap��e in in patient�� patient�� patient�� �ith �ith �ith �l�erati�e �l�erati�e �l�erati�e �l�erati�e �oliti��.� �oliti��.� �oliti��.� �oliti��.� �oliti��.�
Ando T et al . Magnifying chromoscopy in UC 2527<br />
Jones JE. Correlations between defined sigmoidoscopic<br />
appearances and other measures <strong>of</strong> disease activity in<br />
ulcerative colitis. Dig Dis Sci 1982; 27: 533-537<br />
3 Riley SA, Mani V, Goodman MJ, Dutt S, Herd ME. Microscopic<br />
activity in ulcerative colitis: what does it mean? Gut 1991; 32:<br />
174-178<br />
4 Ritchie JK, Powell-Tuck J, Lennard-Jones JE. Clinical outcome<br />
<strong>of</strong> the first ten years <strong>of</strong> ulcerative colitis and proctitis. Lancet<br />
1978; 1: 1140-1143<br />
5 Langholz E, Munkholm P, Davidsen M, Binder V. Course <strong>of</strong><br />
ulcerative colitis: analysis <strong>of</strong> changes in disease activity over<br />
years. <strong>Gastroenterology</strong> 1994; 107: 3-11<br />
6 Edward FC, Truelove SC. The course and prognosis <strong>of</strong><br />
ulcerative colitis. Gut 1963; 4: 299-315<br />
7 Selby W. The natural history <strong>of</strong> ulcerative colitis. Baillieres Clin<br />
Gastroenterol 1997; 11: 53-64<br />
8 Hiwatashi N, Yao T, Watanabe H, Hosoda S, Kobayashi K,<br />
Saito T, Terano A, Shimoyama T, Muto T. Long-term followup<br />
study <strong>of</strong> ulcerative colitis in Japan. J Gastroenterol 1995; 30<br />
Suppl 8: 13-16<br />
9 Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines<br />
in adults. American College <strong>of</strong> <strong>Gastroenterology</strong>, Practice<br />
Parameters Committee. Am J Gastroenterol 1997; 92: 204-211<br />
10 Rampton DS, McNeil NI, Sarner M. Analgesic ingestion and<br />
other factors preceding relapse in ulcerative colitis. Gut 1983;<br />
24: <strong>18</strong>7-<strong>18</strong>9<br />
11 Riley SA, Mani V, Goodman MJ, Lucas S. Why do patients<br />
with ulcerative colitis relapse? Gut 1990; 31: 179-<strong>18</strong>3<br />
12 Winawer SJ, St John DJ, Bond JH, Rozen P, Burt RW, Waye<br />
JD, Kronborg O, O'Brien MJ, Bishop DT, Kurtz RC. Prevention<br />
<strong>of</strong> colorectal cancer: guidelines based on new data. WHO<br />
Collaborating Center for the Prevention <strong>of</strong> Colorectal Cancer.<br />
Bull <strong>World</strong> Health Organ 1995; 73: 7-10<br />
13 Rosenstock E, Farmer RG, Petras R, Sivak MV Jr, Rankin GB,<br />
Sullivan BH. Surveillance for colonic carcinoma in ulcerative<br />
colitis. <strong>Gastroenterology</strong> 1985; 89: 1342-1346<br />
14 Matsumoto T, Kuroki F, Mizuno M, Nakamura S, Iida M.<br />
Application <strong>of</strong> magnifying chromoscopy for the assessment <strong>of</strong><br />
severity in patients with mild to moderate ulcerative colitis.<br />
Gastrointest Endosc 1997; 46: 400-405<br />
15 Fujiya M, Saitoh Y, Nomura M, Maemoto A, Fujiya K, Watari<br />
J, Ashida T, Ayabe T, Obara T, Kohgo Y. Minute findings<br />
by magnifying colonoscopy are useful for the evaluation <strong>of</strong><br />
ulcerative colitis. Gastrointest Endosc 2002; 56: 535-542<br />
16 Nishio Y, Ando T, Maeda O, Ishiguro K, Watanabe O, Ohmiya<br />
N, Niwa Y, Kusugami K, Goto H. Pit patterns in rectal mucosa<br />
assessed by magnifying colonoscope are predictive <strong>of</strong> relapse in<br />
patients with quiescent ulcerative colitis. Gut 2006; 55: 1768-1773<br />
17 Descos L, Andre F, Andre C, Gillon J, Landais P, Fermanian J.<br />
Assessment <strong>of</strong> appropriate laboratory measurements to reflect<br />
the degree <strong>of</strong> activity <strong>of</strong> ulcerative colitis. Digestion 1983; 28:<br />
148-152<br />
<strong>18</strong> Binder V. A comparison between clinical state, macroscopic and<br />
microscopic appearances <strong>of</strong> rectal mucosa, and cytologic picture<br />
<strong>of</strong> mucosal exudate in ulcerative colitis. Scand J Gastroenterol 1970;<br />
5: 627-632<br />
19 Alemayehu G, Jarnerot G. Colonoscopy during an attack <strong>of</strong><br />
severe ulcerative colitis is a safe procedure and <strong>of</strong> great value<br />
in clinical decision making. Am J Gastroenterol 1991; 86: <strong>18</strong>7-190<br />
20 Carbonnel F, Lavergne A, Lemann M. Bitoun A, Valleur<br />
P, Hautefeuille P, Galian A, Modigliani R, Rambaud JC.<br />
Colonoscopy <strong>of</strong> acute colitis. A safe and reliable tool for<br />
assessment <strong>of</strong> severity. Dig Dis Sci 1994; 39: 1550-1557<br />
21 Blackstone M. Endoscopic interpretation normal and<br />
pathologic appearances <strong>of</strong> the gastrointestinal tract. New<br />
York: Raven Press; 1984<br />
22 Baron JH, Connell AM, Lennard-Jones JE. Variation between<br />
observers in describing mucosal appearances in proctocolitis.<br />
Br Med J 1964; 1: 89-92<br />
23 Gomes P, du Boulay C, Smith CL, Holdstock G. Relationship<br />
between disease activity indices and colonoscopic findings in<br />
patients with colonic inflammatory bowel disease. Gut 1986;<br />
27: 92-95<br />
24 Holmquist L, Ahren C, Fallstrom SP. Clinical disease activity<br />
and inflammatory activity in the rectum in relation to mucosal<br />
inflammation assessed by colonoscopy. A study <strong>of</strong> children<br />
and adolescents with chronic inflammatory bowel disease.<br />
Acta Paediatr Scand 1990; 79: 527-534<br />
25 Watts JM, Thompson H, Goligher JC. Sigmoidoscopy and<br />
cytology in the detection <strong>of</strong> microscopic disease <strong>of</strong> the rectal<br />
mucosa in ulcerative colitis. Gut 1966; 7: 288-294<br />
26 Riley SA, Mani V, Goodman MJ, Herd ME, Dutt S, Turnberg<br />
LA. Comparison <strong>of</strong> delayed release 5 aminosalicylic acid<br />
(mesalazine) and sulphasalazine in the treatment <strong>of</strong> mild to<br />
moderate ulcerative colitis relapse. Gut 1988; 29: 669-674<br />
27 Korelitz BI, Sommers SC. Responses to drug therapy in ulcerative<br />
colitis. Evaluation by rectal biopsy and histopathological changes.<br />
Am J Gastroenterol 1975; 64: 365-370<br />
28 Theodossi A, Spiegelhalter DJ, Jass J, Firth J, Dixon M, Leader<br />
M, Levison DA, Lindley R, Filipe I, Price A. Observer variation<br />
and discriminatory value <strong>of</strong> biopsy features in inflammatory<br />
bowel disease. Gut 1994; 35: 961-968<br />
29 Levine TS, Tzardi M, Mitchell S, Sowter C, Price AB. Diagnostic<br />
difficulty arising from rectal recovery in ulcerative colitis. J Clin<br />
Pathol 1996; 49: 319-323<br />
30 Rao SS, Holdsworth CD, Read NW. Symptoms and stool<br />
patterns in patients with ulcerative colitis. Gut 1988; 29: 342-345<br />
31 Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis<br />
and colorectal cancer. A population-based study. N Engl J Med<br />
1990; 323: 1228-1233<br />
32 Crohn BB, Rosenberg H. Sigmoidoscopic picture <strong>of</strong> chronic<br />
ulcerative colitis (non-specific). Am J Med Sci 1925; 170: 220-228<br />
33 Bansal P, Sonnenberg A. Risk factors <strong>of</strong> colorectal cancer in<br />
inflammatory bowel disease. Am J Gastroenterol 1996; 91: 44-48<br />
34 Collins RH Jr, Feldman M, Fordtran JS. Colon cancer,<br />
dysplasia, and surveillance in patients with ulcerative colitis.<br />
A critical review. N Engl J Med 1987; 316: 1654-1658<br />
35 Choi PM, Zelig MP. Similarity <strong>of</strong> colorectal cancer in Crohn's<br />
disease and ulcerative colitis: implications for carcinogenesis<br />
and prevention. Gut 1994; 35: 950-954<br />
36 Fogt F, Vortmeyer AO, Goldman H, Giordano TJ, Merino<br />
MJ, Zhuang Z. Comparison <strong>of</strong> genetic alterations in colonic<br />
adenoma and ulcerative colitis-associated dysplasia and<br />
carcinoma. Hum Pathol 1998; 29: 131-136<br />
37 Blackstone MO, Riddell RH, Rogers BH, Levin B. Dysplasiaassociated<br />
lesion or mass (DALM) detected by colonoscopy in<br />
long-standing ulcerative colitis: an indication for colectomy.<br />
<strong>Gastroenterology</strong> 1981; 80: 366-374<br />
38 Butt JH, Konishi F, Morson BC, Lennard-Jones JE, Ritchie JK.<br />
Macroscopic lesions in dysplasia and carcinoma complicating<br />
ulcerative colitis. Dig Dis Sci 1983; 28: <strong>18</strong>-26<br />
39 Riddell RH, Goldman H, Ransoh<strong>of</strong>f DF, Appelman HD, Fenoglio<br />
CM, Haggitt RC, Ahren C, Correa P, Hamilton SR, Morson<br />
BC. Dysplasia in inflammatory bowel disease: standardized<br />
classification with provisional clinical applications. Hum Pathol<br />
1983; 14: 931-968<br />
40 Greenstein AJ, Sachar DB, Smith H, Pucillo A, Papatestas<br />
AE, Kreel I, Geller SA, Janowitz HD, Aufses AH Jr. Cancer in<br />
universal and left-sided ulcerative colitis: factors determining<br />
risk. <strong>Gastroenterology</strong> 1979; 77: 290-294<br />
41 Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis<br />
and colorectal cancer. A population-based study. N Engl J Med<br />
1990; 323: 1228-1233<br />
42 Leidenius M, Kellokumpu I, Husa A, Riihela M, Sipponen P.<br />
Dysplasia and carcinoma in longstanding ulcerative colitis:<br />
an endoscopic and histological surveillance programme. Gut<br />
1991; 32: 1521-1525<br />
43 Gyde SN, Prior P, Allan RN, Stevens A, Jewell DP, Truelove<br />
SC, L<strong>of</strong>berg R, Brostrom O, Hellers G. Colorectal cancer in<br />
ulcerative colitis: a cohort study <strong>of</strong> primary referrals from<br />
three centres. Gut 1988; 29: 206-217<br />
44 Eaden JA, Abrams KR, Mayberry JF. The risk <strong>of</strong> colorectal<br />
cancer in ulcerative colitis: a meta-analysis. Gut 2001; 48: 526-535<br />
45 Devroede GJ, Taylor WF, Sauer WG, Jackman RJ, Stickler GB.<br />
Cancer risk and life expectancy <strong>of</strong> children with ulcerative<br />
colitis. N Engl J Med 1971; 285: 17-21<br />
www.wjgnet.com
2528 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
46 Rutter M, Saunders B, Wilkinson K, Rumbles S, Sch<strong>of</strong>ield G,<br />
Kamm M, Williams C, Price A, Talbot I, Forbes A. Severity<br />
<strong>of</strong> inflammation is a risk factor for colorectal neoplasia in<br />
ulcerative colitis. <strong>Gastroenterology</strong> 2004; 126: 451-459<br />
47 Heimann TM, Oh SC, Martinelli G, Szporn A, Luppescu N,<br />
Lembo CA, Kurtz RJ, Fasy TM, Greenstein AJ. Colorectal<br />
carcinoma associated with ulcerative colitis: a study <strong>of</strong><br />
prognostic indicators. Am J Surg 1992; 164: 13-17<br />
48 Ransoh<strong>of</strong>f DF. Colon cancer in ulcerative colitis. <strong>Gastroenterology</strong><br />
1988; 94: 1089-1091<br />
49 Nugent FW, Haggitt RC, Gilpin PA. Cancer surveillance in<br />
ulcerative colitis. <strong>Gastroenterology</strong> 1991; 100: 1241-1248<br />
50 Sugita A, Sachar DB, Bodian C, Ribeiro MB, Aufses AH Jr,<br />
Greenstein AJ. Colorectal cancer in ulcerative colitis. Influence<br />
<strong>of</strong> anatomical extent and age at onset on colitis-cancer interval.<br />
Gut 1991; 32: 167-169<br />
51 Farmer RG, Easley KA, Rankin GB. Clinical patterns, natural<br />
history, and progression <strong>of</strong> ulcerative colitis. A long-term<br />
follow-up <strong>of</strong> 1116 patients. Dig Dis Sci 1993; 38: 1137-1146<br />
52 Leijonmarck CE, L<strong>of</strong>berg R, Ost A, Hellers G. Long-term results<br />
<strong>of</strong> ileorectal anastomosis in ulcerative colitis in Stockholm<br />
County. Dis Colon Rectum 1990; 33: 195-200<br />
53 Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH,<br />
Mulrow CD, Woolf SH, Glick SN, Ganiats TG, Bond JH, Rosen<br />
L, Zapka JG, Olsen SJ, Giardiello FM, Sisk JE, Van Antwerp R,<br />
Brown-Davis C, Marciniak DA, Mayer RJ. Colorectal cancer<br />
screening: clinical guidelines and rationale. <strong>Gastroenterology</strong><br />
1997; 112: 594-642<br />
54 Hata K, Watanabe T, Kazama S, Suzuki K, Shinozaki M, Yokoyama<br />
T, Matsuda K, Muto T, Nagawa H. Earlier surveillance<br />
colonoscopy programme improves survival in patients with<br />
ulcerative colitis associated colorectal cancer: results <strong>of</strong> a<br />
23-year surveillance programme in the Japanese population.<br />
Br J Cancer 2003; 89: 1232-1236<br />
55 Morson BC, Pang LS. Rectal biopsy as an aid to cancer control<br />
in ulcerative colitis. Gut 1967; 8: 423-434<br />
56 Hulten L, Kewenter J, Ahren C. Precancer and carcinoma<br />
in chronic ulcerative colitis. A histopathological and clinical<br />
investigation. Scand J Gastroenterol 1972; 7: 663-669<br />
57 The role <strong>of</strong> colonoscopy in the management <strong>of</strong> patients<br />
with inflammatory bowel disease. American Society for<br />
Gastrointestinal Endoscopy. Gastrointest Endosc 1998; 48: 689-690<br />
58 Ransoh<strong>of</strong>f DF, Riddell RH, Levin B. Ulcerative colitis and<br />
colonic cancer. Problems in assessing the diagnostic usefulness<br />
<strong>of</strong> mucosal dysplasia. Dis Colon Rectum 1985; 28: 383-388<br />
59 Rutter MD, Saunders BP, Sch<strong>of</strong>ield G, Forbes A, Price AB,<br />
Talbot IC. Pancolonic indigo carmine dye spraying for the<br />
detection <strong>of</strong> dysplasia in ulcerative colitis. Gut 2004; 53: 256-260<br />
60 Hata K, Watanabe T, Motoi T, Nagawa H. Pitfalls <strong>of</strong> pit<br />
pattern diagnosis in ulcerative colitis-associated dysplasia.<br />
<strong>Gastroenterology</strong> 2004; 126: 374-376<br />
61 Hurlstone DP, McAlindon ME, Sanders DS, Koegh R, Lobo<br />
AJ, Cross SS. Further validation <strong>of</strong> high-magnification<br />
chromoscopic-colonoscopy for the detection <strong>of</strong> intraepithelial<br />
www.wjgnet.com<br />
neoplasia and colon cancer in ulcerative colitis. <strong>Gastroenterology</strong><br />
2004; 126: 376-378<br />
62 Kiesslich R, Fritsch J, Holtmann M, Koehler HH, Stolte M,<br />
Kanzler S, Nafe B, Jung M, Galle PR, Neurath MF. Methylene<br />
blue-aided chromoendoscopy for the detection <strong>of</strong> intraepithelial<br />
neoplasia and colon cancer in ulcerative colitis. <strong>Gastroenterology</strong><br />
2003; 124: 880-888<br />
63 Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H,<br />
Watanabe H. Diagnosis <strong>of</strong> colorectal tumorous lesions by<br />
magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14<br />
64 Sada M, Igarashi M, Yoshizawa S, Kobayashi K, Katsumata T,<br />
Saigenji K, Otani Y, Okayasu I, Mitomi H. Dye spraying and<br />
magnifying endoscopy for dysplasia and cancer surveillance<br />
in ulcerative colitis. Dis Colon Rectum 2004; 47: <strong>18</strong>16-<strong>18</strong>23<br />
65 Bernstein CN, Shanahan F, Weinstein WM. Are we telling<br />
patients the truth about surveillance colonoscopy in ulcerative<br />
colitis? Lancet 1994; 343: 71-74<br />
66 Lynch DA, Lobo AJ, Sobala GM, Dixon MF, Axon AT. Failure<br />
<strong>of</strong> colonoscopic surveillance in ulcerative colitis. Gut 1993; 34:<br />
1075-1080<br />
67 Axon AT. Cancer surveillance in ulcerative colitis--a time for<br />
reappraisal. Gut 1994; 35: 587-589<br />
68 Jonsson B, Ahsgren L, Andersson LO, Stenling R, Rutegard<br />
J. Colorectal cancer surveillance in patients with ulcerative<br />
colitis. Br J Surg 1994; 81: 689-691<br />
69 Woolrich AJ, DaSilva MD, Korelitz BI. Surveillance in the<br />
routine management <strong>of</strong> ulcerative colitis: the predictive value<br />
<strong>of</strong> low-grade dysplasia. <strong>Gastroenterology</strong> 1992; 103: 431-438<br />
70 Connell WR, Lennard-Jones JE, Williams CB, Talbot IC,<br />
Price AB, Wilkinson KH. Factors affecting the outcome<br />
<strong>of</strong> endoscopic surveillance for cancer in ulcerative colitis.<br />
<strong>Gastroenterology</strong> 1994; 107: 934-944<br />
71 Befrits R, Ljung T, Jaramillo E, Rubio C. Low-grade dysplasia<br />
in extensive, long-standing inflammatory bowel disease: a<br />
follow-up study. Dis Colon Rectum 2002; 45: 615-620<br />
72 Lim CH, Dixon MF, Vail A, Forman D, Lynch DA, Axon AT.<br />
Ten year follow up <strong>of</strong> ulcerative colitis patients with and<br />
without low grade dysplasia. Gut 2003; 52: 1127-32<br />
73 Lennard-Jones JE, Melville DM, Morson BC, Ritchie JK, Williams<br />
CB. Precancer and cancer in extensive ulcerative colitis: findings<br />
among 401 patients over 22 years. Gut 1990; 31: 800-806<br />
74 Suzuki K, Muto T, Shinozaki M, Yokoyama T, Matsuda K,<br />
Masaki T. Differential diagnosis <strong>of</strong> dysplasia-associated lesion<br />
or mass and coincidental adenoma in ulcerative colitis. Dis<br />
Colon Rectum 1998; 41: 322-327<br />
75 Rubin PH, Friedman S, Harpaz N, Goldstein E, Weiser J,<br />
Schiller J, Waye JD, Present DH. Colonoscopic polypectomy<br />
in chronic colitis: conservative management after endoscopic<br />
resection <strong>of</strong> dysplastic polyps. <strong>Gastroenterology</strong> 1999; 117:<br />
1295-1300<br />
76 Engelsgjerd M, Farraye FA, Odze RD. Polypectomy may be<br />
adequate treatment for adenoma-like dysplastic lesions in<br />
chronic ulcerative colitis. <strong>Gastroenterology</strong> 1999; 117: 1288-1294;<br />
discussion 1488-1491<br />
S- Editor Liu Y E- Editor Wang HF
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2529-2534<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Magnetic resonance cholangiopancreatography: A useful tool<br />
in the evaluation <strong>of</strong> pancreatic and biliary disorders<br />
Ahmet Mesrur Halefoglu<br />
Ahmet Mesrur Halefoglu, Department <strong>of</strong> Radiology, Sisli Etfal<br />
Training and Research Hospital, 34360, Sisli, Istanbul, Turkey<br />
Correspondence to: Ahmet Mesrur Halefoglu, MD, Department<br />
<strong>of</strong> Radiology, Sisli Etfal Training and Research Hospital, 34360,<br />
Sisli, Istanbul, Turkey. halefoglu@hotmail.com<br />
Telephone: +90-212-2795643 Fax: +90-212-2415015<br />
Received: 2007-02-16 Accepted: 2007-03-21<br />
Abstract<br />
Magnetic resonance cholangiopancreatography<br />
(MRCP) is being used with increasing frequency as<br />
a noninvasive alternative to diagnostic retrograde<br />
cholangiopancreatography (ERCP). The aim <strong>of</strong> this<br />
pictorial review is to demonstrate the usefulness <strong>of</strong><br />
MRCP in the evaluation <strong>of</strong> pancreatic and biliary system<br />
disorders. Because the recently developed techniques<br />
allows improved spatial resolution and permits imaging<br />
<strong>of</strong> the entire pancreaticobiliary tract during a single<br />
breath hold, MRCP is <strong>of</strong> proven utility in a variety <strong>of</strong><br />
pancreatic and biliary disorders. It uses MR imaging to<br />
visualize fluid in the biliary and pancreatic ducts as high<br />
signal intensity on T2 weighted sequences and is the<br />
newest modality for pancreatic and biliary duct imaging.<br />
Herein, we present the clinical applications <strong>of</strong> MRCP<br />
in a variety <strong>of</strong> pancreaticobiliary system disorders and<br />
conclude that it is an important diagnostic tool in terms<br />
<strong>of</strong> imaging <strong>of</strong> the pancreaticobiliary ductal system.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Bile ducts abnormalities; Bile ducts calculi;<br />
Bile ducts neoplasms; MR cholangiopancreatography;<br />
Pancreatic ducts; Pancreas; Neoplasms<br />
Halefoglu AM. Magnetic resonance cholangiopancreatography:<br />
A useful tool in the evaluation <strong>of</strong> pancreatic and biliary<br />
disorders. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>): 2529-2534<br />
http://www.wjgnet.com/1007-9327/13/2529.asp<br />
INTRODUCTION<br />
Magnetic resonance cholangiopancreatography (MRCP)<br />
is a noninvasive imaging technique that accurately depicts<br />
the morphological features <strong>of</strong> the biliary and pancreatic<br />
ducts. By using heavily T2 weighted sequences, the signal<br />
<strong>of</strong> static or slow-moving fluid-filled structures such as the<br />
REVIEW<br />
bile and pancreatic ducts is greatly increased, resulting in<br />
increased duct-to-background contrast. Recent studies have<br />
shown that MRCP is comparable with invasive retrograde<br />
cholangiopancreatography (ERCP) for diagnosis <strong>of</strong><br />
extrahepatic bile duct and pancreatic duct abnormalities<br />
such as choledocholithiasis [1-3] , malignant obstruction <strong>of</strong> the<br />
bile and pancreatic ducts [1,2] , congenital anomalies [1,4] , and<br />
chronic pancreatitis [5,6] . Common indications for MRCP<br />
usually include unsuccessful ERCP or a contraindication to<br />
ERCP and the presence <strong>of</strong> biliary-enteric anastomoses. (e.g.<br />
choledochojejunostomy, Billroth 2 anastomosis). In some<br />
institutions, MRCP is becoming the initial imaging tool for<br />
the biliary system, with ERCP reserved for only therapeutic<br />
indications. In this article we present clinical applications <strong>of</strong><br />
MRCP in the pancreaticobiliary system pathologies including<br />
choledocholithiasis, biliary strictures, chronic pancreatitis,<br />
benign and malignant pancreatic neoplasms, pancreatic<br />
pseudocysts, congenital abnormalities and postsurgical<br />
biliary tract alterations.<br />
TECHNICAL CONSIDERATIONS<br />
During the MRCP examinations, respiratory motion<br />
induced blurring has limited demonstration <strong>of</strong> the biliary<br />
and pancreatic ductal system and different approaches have<br />
been considered to overcome this problem. As a result,<br />
the technical history <strong>of</strong> MRCP parallels the evolution <strong>of</strong><br />
progressively faster T2 weighted imaging sequences, i.e.,<br />
from gradient-echo, to fast spin echo (FSE), to single-shot<br />
fast spin-echo (SSFSE) [7] . SSFSE is a recently developed<br />
ultrafast T2 weighted sequence, which allows subsecond<br />
slice acquisition. This largely overcomes the problem <strong>of</strong><br />
motion artifact in MRCP, because physiologic motion is<br />
“frozen”, and imaging <strong>of</strong> the biliary and pancreatic ducts<br />
can be performed in a single breath-hold [8] .<br />
SSFSE is the current sequence <strong>of</strong> choice for MRCP,<br />
because it essentialy eliminates the problem <strong>of</strong> motion<br />
artifact, and because <strong>of</strong> greater contrast-to-noise ratio<br />
and increased spatial resolution when compared with FSE<br />
or gradient-echo-based T2 weighted sequences [9] . MRCP<br />
is usually performed by using SSFSE s<strong>of</strong>tware and both<br />
a thick-collimation (single-section) and thin-collimation<br />
(multisection) technique with a torso phased-array coil. The<br />
coronal plane is used to provide a cholangiographic display,<br />
and the axial plane is used to evaluate the pancreatic duct and<br />
the distal common bile duct. In addition we perform threedimensional<br />
reconstruction by using a maximum intensity<br />
projection (MIP) algorithm on the thin-collimation source<br />
images. Although the thick-collimation and MIP images<br />
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more closely resemble conventional cholangiograms and<br />
are familiar to many clinicians, spatial resolution is degraded<br />
because <strong>of</strong> volume-averaging effects. Diagnostic desicions<br />
are usually made on the basis <strong>of</strong> the thin-collimation<br />
source images, however, MIP images <strong>of</strong>ten allow depiction<br />
<strong>of</strong> a greater length <strong>of</strong> duct on a single image than on<br />
any one thin-collimation source image. In addition, MIP<br />
images are useful in the three-dimensional depiction <strong>of</strong><br />
ductal anatomy and in planning surgical procedures and<br />
radiation therapy. On the other hand, the source images,<br />
which provide greater spatial resolution, must be carefully<br />
scrutinized so as not to overlook small luminal filling defects<br />
and strictures, which may be obscured on the thickercollimation<br />
images.<br />
In a study <strong>of</strong> 108 patients with a variety <strong>of</strong> biliary<br />
and pancreatic diseases, bile duct stenoses, dilatation, and<br />
stones were all better seen on source thin slices than on<br />
either MIP reconstruction or single thick slice MRCP [10] .<br />
Another disadvantage <strong>of</strong> such techniques is that<br />
periductal structures are deliberately excluded from the<br />
final images, even though extraluminal detail may be <strong>of</strong><br />
critical importance, as in the assessment <strong>of</strong> neoplastic duct<br />
obstruction.<br />
PATIENT PREPARATION<br />
Patients should be fasting for approximately 4-6 h prior to<br />
the exam to promote gallbladder filling and gastric emptying.<br />
Some authors have advocated the use <strong>of</strong> glugacon to<br />
suspend peristalsis, but use <strong>of</strong> rapid pulse sequences obviated<br />
this requirement. We do not need an exogenous contrast<br />
to demonstrate the pancreatic and biliary ducts. The<br />
long T2 <strong>of</strong> fluid compared with that <strong>of</strong> surrounding s<strong>of</strong>t<br />
tissues and <strong>of</strong> calculi provides sufficient intrinsic contrast.<br />
Administration <strong>of</strong> a negative oral contrast helps reduce the<br />
signal intensity from overlapping fluid in the stomach and<br />
duedonum.<br />
MRCP IN CHOLEDOCHOLITHIASIS<br />
B C<br />
Figure 1 A: Coronal FSE thin section source image, numerous hypointense calculi are seen filling the gall -bladder. There is also a small hypointense calcule located<br />
at the distal CBD; B: Coronal FSE thin section source image, an approximately 3 cm long segment stricture along the distal CBD is seen in a patient with history <strong>of</strong> blunt<br />
abdominal trauma; C: Axial FSE thin section source image, multifocal strictures and dilatations <strong>of</strong> the intrahepatic biliary ducts causing a beaded appearance in a patient<br />
with sclerosing cholangitis.<br />
MRCP is comparable with ERCP in detection <strong>of</strong> choledocholithiasis<br />
and superior to CT and US [2,3] . Numerous<br />
studies have shown sensitivities <strong>of</strong> 81%-100% and<br />
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specificities <strong>of</strong> 85%-100% [11] .<br />
Biliary stones, independently <strong>of</strong> calcium content,<br />
present almost always a low signal intensity on MR images.<br />
Therefore, the stone is identified as a round or oval-<br />
shaped “filling defect” within the common bile duct (CBD),<br />
surrounded by the high signal intensity bile (Figure 1A).<br />
Although spatial resolution <strong>of</strong> MRCP is lower than ERCP,<br />
the higher contrast resolution allows 2 to 3 mm stones to<br />
be easily detected [12] .<br />
It is crucial to scrutinize the thin, source images<br />
because the sensitivity for detection <strong>of</strong> small stones<br />
decreases with an increase in section thickness owing to<br />
volume averaging <strong>of</strong> high signal intensity bile surrounding<br />
the stone.<br />
Nevertheless, different pitfalls can be observed which<br />
requires correct identification in order to avoid wrong<br />
diagnoses. They are represented by: a-artefacts on MIP<br />
reconstructed images, b-CBD completely filled with stones,<br />
c-pneumobilia, and, d-differential diagnoses between air<br />
bubles and small stones.<br />
MRCP IN BENIGN BILIARY STRICTURES<br />
Benign biliary strictures are the result <strong>of</strong> surgical injury in<br />
90%-95% <strong>of</strong> cases (laparoscopic cholecystectomy, gastric<br />
and hepatic resection, biliary-enteric anastomoses, post<br />
liver transplantation), external penetrating or blunt trauma,<br />
inflammation associated with lithiasis, chronic pancreatitis,<br />
stricture <strong>of</strong> the papillary region, toxic or ischaemic lesion<br />
<strong>of</strong> the hepatic artery or primary infection such as in<br />
primary sclerosing cholangitis [13] .<br />
MRCP has been shown to be comparable with ERCP<br />
in demonstrating the location and extent <strong>of</strong> strictures <strong>of</strong><br />
the extrahepatic bile duct (Figure 1B), with sensitivities<br />
<strong>of</strong> 91%-100% [14] . However, the accuracy in detections<br />
<strong>of</strong> strictures <strong>of</strong> the intrahepatic bile ducts is under<br />
investigation.<br />
MRCP IN SCLEROSING CHOLANGITIS<br />
Sclerosing cholangitis is a fibrosing, inflammatory process<br />
<strong>of</strong> the bile ducts that leads to sclerosis and stenosis <strong>of</strong><br />
both intrahepatic and extrahepatic bile ducts.
Halefoglu AM. MRCP in the pancreaticobiliary disorders 2531<br />
A B C D<br />
Figure 2 A: Coronal MIP image, a hypointense solid mass involving both the left and right main hepatic ducts representing Klatskin tumor is seen. There is also proximal<br />
dilatation <strong>of</strong> the bile ducts before the mass; B: Coronal MIP image, a dorsal pancreatic duct is seen coursing the CBD and draining into the minor papilla. A smaller ventral<br />
pancreatic duct is draining into the major papilla together with the CBD; C: Coronal MIP image, clearly depicts the “double duct sign”; D: Coronal MIP image, a small<br />
periampullary carcinoma leading to mild dilatation <strong>of</strong> both CBD and pancreatic duct.<br />
Strictures are multifocal and alternate with slight<br />
dilatation or normal-caliber bile ducts, producing a beaded<br />
or “pruned tree” appearence (Figure 1C).<br />
Because MRCP is not as sensitive as ERCP to the early<br />
peripheral ductal changes <strong>of</strong> sclerosing cholangitis, it should<br />
be reserved for diagnosis <strong>of</strong> complications or follow up <strong>of</strong><br />
more advanced cases.<br />
MRCP IN CHOLANGIOCARCINOMA<br />
Cholangiocarcinoma may present as a stricture, involving<br />
the CBD (30%-36%), the common hepatic duct<br />
(15%-30%), the biliary bifurcation, with the typical aspect<br />
<strong>of</strong> Klatskin tumour (10%-26%), and the intrahepatic ducts<br />
(8%-13%) with no evidence <strong>of</strong> mass lesion or as a nodular<br />
process with intrahepatic solid mass. The MRCP features<br />
are a sudden biliary obstruction with dilatation <strong>of</strong> bile<br />
ducts above. In the case <strong>of</strong> Klatskin tumours, information<br />
regarding the involvement only <strong>of</strong> the right or left biliary<br />
system or both can be easily obtained, with important<br />
consequences on therapeutic approach (Figure 2A).<br />
Similiar to other neoplastic lesions, conventional MR<br />
images are needed for correct lesion identification<br />
and staging. In particular, for cholangiocarcinoma, T1<br />
weighted images after contrast medium injection can be<br />
very helpful in correct identification <strong>of</strong> the lesion and <strong>of</strong><br />
its relationship with surrounding organs, although in the<br />
case <strong>of</strong> stenosing lesion, no expansile process is usually<br />
identified.<br />
MRCP IN BILIARY INJURIES<br />
Initial studies suggest that iatrogenic biliary injuries are well<br />
demonstrated at MRCP [15] . Bile leaks result in accumulation<br />
<strong>of</strong> fluid, usually in the subhepatic space, which is readily<br />
detected at MRCP. But MRCP can not determine if a<br />
leak is active. Recently, there have been reports <strong>of</strong> use<br />
<strong>of</strong> selective hepato-biliary contrast agent, mangafodipir.<br />
This is metabolized by hepatocytes and excreted in bile.<br />
This agent may prove useful in noninvasive detection <strong>of</strong><br />
active bile leaks [16] , but prospective trials have not yet been<br />
published.<br />
MRCP IN THE CONGENITAL ANOMALIES<br />
OF THE BILIARY AND PANCREATIC<br />
DUCTS<br />
A number <strong>of</strong> congenital variants in biliary duct anatomy<br />
are <strong>of</strong> surgical significance, because they have been<br />
shown to increase the risk <strong>of</strong> bile duct injury during<br />
cholecystectomy. Such variants include a low cystic duct<br />
insertion, a medial cystic duct insertion, a long parallel<br />
course <strong>of</strong> the cystic and common hepatic ducts, a short<br />
cystic duct, and an abberant right posterior sectorial duct<br />
draining to the cystic duct or to the common hepatic<br />
duct [4] .<br />
Using conventional cholangiography as the standart <strong>of</strong><br />
reference, MRCP had a sensitivity and specificity <strong>of</strong> 86%<br />
and 100% in the diagnosis <strong>of</strong> cystic duct variants, and 71%<br />
and 100% in the diagnosis <strong>of</strong> aberrant right hepatic duct,<br />
respectively [4] .<br />
In normal individuals, the main pancreatic duct<br />
(duct <strong>of</strong> Wirsung) drains through the major papilla;<br />
this duct is the major drainage route <strong>of</strong> the pancreas in<br />
91% <strong>of</strong> individuals. The accessory pancreatic duct (duct<br />
<strong>of</strong> Santorini) drains through the minor papilla and is<br />
present in 44% <strong>of</strong> individuals. Pancreas divisum, the most<br />
common anatomic variant <strong>of</strong> the pancreas, results from<br />
failure <strong>of</strong> fusion <strong>of</strong> the dorsal and ventral pancreatic ducts<br />
and may be associated with an increase prevalance <strong>of</strong> acute<br />
pancreatitis [5] . The larger, dominant dorsal pancreatic duct,<br />
which drains the pancreatic tail, body, and superior head,<br />
courses anterior to the CBD and drains into the minor<br />
papilla separately from the CBD, superior to the major<br />
papilla. The smaller ventral duct, which drains the inferior<br />
pancreatic head and uncinate process, accompanies the<br />
CBD into the major papilla (Figures 2B and 3A). Bret<br />
et al [17] reported an accuracy <strong>of</strong> 100% for MRCP in the<br />
diagnosis <strong>of</strong> pancreas divisum.<br />
MRCP IN CHRONIC PANCREATITIS<br />
The MRCP diagnostic criteria for chronic pancreatitis<br />
include duct dilatation, narrowing, stricture, or irregularity<br />
[7] . Other possible imaging findings are irregularity <strong>of</strong><br />
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2532 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
A B C<br />
D<br />
pancreatic contour, pseudocysts, and ductal filling defects<br />
due to stones, debris or mucinous plugs. In advanced<br />
chronic pancreatitis, the duct dilatation is more marked and<br />
can be accompanied by CBD dilatation producing “double<br />
duct sign” as in the case <strong>of</strong> pancreatic head carcinoma<br />
(Figure 3B).<br />
In chronic pancreatitis intraductal calculi may be seen.<br />
These calculi are seen as low signal filling defects surrounded<br />
by high signal intensity pancreatic fluid (meniscus sign).<br />
In severe pancreatitis, side branches have a “chain <strong>of</strong> lake”<br />
appearence.<br />
Soto et al [<strong>18</strong>] found the sensitivity <strong>of</strong> MRCP for dilatation<br />
as 87%-100%, for narrowing 75%, and for ductal calculi<br />
100%. The authors conclude that MRCP can accurately<br />
demonstrate pancreatic duct abnormalities in chronic<br />
pancreatitis.<br />
However, because MRCP is probably not sensitive<br />
to the early side-branch changes <strong>of</strong> chronic pancreatitis,<br />
MRCP should be reserved for diagnosis <strong>of</strong> complications<br />
or follow-up <strong>of</strong> more advanced cases. ERCP is more<br />
sensitive to early side-branch changes because <strong>of</strong> its<br />
increased spatial resolution.<br />
PANCREATIC PSEUDOCYST<br />
Pancreatic pseudocysts are encapsulated fluid collections<br />
that may occur in association with acute or chronic<br />
pancreatitis. (Figure 3C) MRCP is more sensitive than<br />
ERCP in detection <strong>of</strong> pseudocysts because less than 50%<br />
E<br />
Figure 3 A: Coronal SSFSE thin section source image, the same duct abnormalities is clearly seen in a different patient with pancreas divisum; B: Coronal SSFSE<br />
thin section source image, CBD and pancreatic duct showing conspicuous dilatation in a chronic pancreatitis patient; C: Coronal FSE thin section source image, large<br />
pseudocyst formations are seen throughout the pancreas obscuring the CBD and pancreatic duct; D: Coronal FSE thin section source image, a large heterogeneous<br />
high signal intensity pancreatic head adenocarcinoma causing dilatation <strong>of</strong> both CBD and pancreatic duct is seen; E: Coronal MIP image, there is moderate dilatation and<br />
following abrupt but smooth tapering <strong>of</strong> CBD draining into the jejunum (choledochojejunostomy), also a small dilated cystic duct is seen. Remnant pancreatic duct in the tail<br />
draining into the afferent jejunal loop (pancreaticojejunostomy). The patient had a history <strong>of</strong> whipple operation for pancreatic head adenocarcinoma.<br />
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<strong>of</strong> pseudocysts fill with contrast material at ERCP [19] .<br />
However MRCP is less sensitive in demonstrating the site<br />
<strong>of</strong> communication with the pancreatic duct.<br />
Although as many as 60% <strong>of</strong> pseudocysts may<br />
resolve spontaneously, others will become complicated<br />
by infection or hemorrhage. MRI and MRCP are useful<br />
in demonstrating pseudocysts and possibly their ductal<br />
communications as well as in establishing the presence <strong>of</strong><br />
associated hemorrhage without the risk <strong>of</strong> infecting the<br />
pseudocyst as may occur at ERCP.<br />
MRCP IN NEOPLASTIC BILIARY OR<br />
PANCREATIC DUCT OBSTRUCTION<br />
Approximately 90% <strong>of</strong> malignant pancreatic neoplasms<br />
are ductal in origin with most being adenocarcinomas.<br />
Pancreatic carcinoma is seen as a focal mass in 95% <strong>of</strong><br />
cases, whereas diffuse involvement <strong>of</strong> the gland occurs in<br />
the remaining 5% [20] . Of these focal carcinomas, 62% are<br />
located in the pancreatic head, with the remainder located<br />
in the body (26%) and tail (12%) <strong>of</strong> the pancreas [20] .<br />
The MRCP findings <strong>of</strong> pancreatic carcinoma include<br />
encasement and obstruction <strong>of</strong> the pancreatic duct or bile<br />
duct. Dilatation <strong>of</strong> both ducts constitutes the “double duct<br />
sign”, which is highly suggestive <strong>of</strong> but no diagnostic for<br />
malignancy [14] . (Figures 2C and Figure 3D) In pancreatic<br />
head carcinoma, biliary and pancreatic duct dilatation<br />
occurs in 77% <strong>of</strong> cases, biliary duct dilatation in 9%, and<br />
pancreatic duct dilatation in 12% [20] .
Halefoglu AM. MRCP in the pancreaticobiliary disorders 2533<br />
However, a normal-sized pancreatic duct should not<br />
cause this diagnosis to be excluded because the caliber<br />
will be normal in up to 20% <strong>of</strong> patients with pancreatic<br />
malignancy causing bile duct obstruction.<br />
In a study <strong>of</strong> breath-hold SSFSE MRCP in 32 patients<br />
with pathologically confirmed neoplastic duct obstruction,<br />
the level <strong>of</strong> obstruction was correctly identified in 27<br />
(84%) and 28 (88%) <strong>of</strong> the 32 cases by two independent<br />
observers, respectively, and the site <strong>of</strong> underlying tumor<br />
was correctly identified in 27 (84%) and 29 (91%) cases [21] .<br />
In cases <strong>of</strong> periampullary carcinoma, apart from the<br />
CBD obstruction, high grade obstruction with abrupt<br />
termination and mild dilatation <strong>of</strong> the pancreatic duct is<br />
usually present [22] (Figure 2D).<br />
MRCP is also useful in the evaluation <strong>of</strong> intraductal<br />
papillary mucinous tumors. These tumors arise from the<br />
epithelium <strong>of</strong> the main pancreatic duct or side branches.<br />
They are slow-growing tumors characterized by production<br />
<strong>of</strong> large amounts <strong>of</strong> mucin. Side-branch ductal<br />
involvement is typically associated with benign adenomas<br />
and a localized cystic parenchymal lesion. Main pancreatic<br />
duct involvement alone presents as diffuse duct dilatation,<br />
gross mucin production, and micropapillary studding, and<br />
is typically associated with malignancy [23,24] . The diagnosis<br />
was traditionally made at ERCP. MRCP is now considered<br />
superior to ERCP because <strong>of</strong> its ability to demonstrate<br />
the full extent <strong>of</strong> ductal involvement, particularly when<br />
obstructing mucin prevents complete ductal opacification<br />
by ERCP [25] . In addition, MRCP can demonstrate main<br />
ductal and side branch stenosis and dilatation, associated<br />
cystic lesions, and communication between these lesions<br />
and the ductal system [26] . Filling defects caused by papillary<br />
projections may also be demonstrated.<br />
PANCREATIC TRAUMA<br />
Pancreatic injuries occur in 2%-12% <strong>of</strong> patients with<br />
blunt abdominal trauma [27] . Disruption <strong>of</strong> the pancreatic<br />
duct is a key prognostic indicator, and early diagnosis is<br />
important. Although CT is a sensitive method for detecting<br />
parenchymal injury, demonstration <strong>of</strong> duct injury <strong>of</strong>ten<br />
requires ERCP [28] . MRCP has recently been advocated as<br />
a noninvasive method for diagnosing pancreatic ductal<br />
injury [29] . In a series <strong>of</strong> seven trauma patients reported by<br />
Soto et al, MRCP accurately demonstrated the status <strong>of</strong><br />
the duct and the site <strong>of</strong> duct transection in all patients [30] .<br />
Though CT will likely remain the mainstay for diagnosis<br />
<strong>of</strong> pancreatic injury, MRCP shows promise in the planning<br />
<strong>of</strong> therapeutic surgical or endoscopic interventions in this<br />
setting [30] .<br />
MRCP IN POSTSURGICAL BILIARY TRACT<br />
ALTERATIONS<br />
Biliary-enteric anostomoses such as choledocho-jejunostomy,<br />
hepaticojejunostomy, and Billroth 2 anostomosis make<br />
it difficult or impossible to access the major papilla at<br />
endoscopy. In patients with such anastomoses, MRCP is the<br />
imaging modality <strong>of</strong> choice for the work-up <strong>of</strong> suspected<br />
pancreaticobiliary disease.<br />
It has been reported that MRCP is 100% sensitive in<br />
detection <strong>of</strong> anastomotic strictures and 90% sensitive in<br />
detection biliary tract stones proximal to the anastomosis [31] .<br />
MRCP is also 100% sensitive in demonstrating the<br />
choledochojejunal anastomosis after a whipple procedure [1]<br />
(Figure 3E).<br />
Close scrutiny <strong>of</strong> the source images is mandatory<br />
because the biliary-enteric anastomosis and stones can be<br />
obscured on the thick-section and MIP images by the high<br />
signal intensity <strong>of</strong> the surrounding bile and bowel fluid.<br />
Strictures may be overestimated on the MIP images [31] .<br />
ADVANTAGES AND LIMITATIONS<br />
A clear advantage <strong>of</strong> this technique is the lack <strong>of</strong> invasiveness.<br />
In addition, MRCP is not limited in patients with<br />
altered anatomy (choledocho or pancreaticojejunostomy,<br />
Billroth 2 etc.) and it is not operator dependent.<br />
The current shortcoming <strong>of</strong> MRCP is its relatively low<br />
spatial resolution which limits the visualization <strong>of</strong> nondilated<br />
pancreatic duct side branches and characterization<br />
<strong>of</strong> strictures. This makes MRCP inable to assess small duct<br />
disease. Examples <strong>of</strong> small duct disease include subtle<br />
intrahepatic duct changes <strong>of</strong> sclerosing cholangitis, and<br />
side branch changes <strong>of</strong> mild chronic pancreatitis. This<br />
limitation is also partially related to the lack <strong>of</strong> duct<br />
distension at MRCP.<br />
CONCLUSION<br />
In summary, MRCP is a non-invasive important tool in the<br />
diagnosis <strong>of</strong> bilio-pancreatic diseases and has a comparable<br />
accuracy to ERCP. Despite relatively low spatial resolution<br />
when compared with ERCP the early assessments <strong>of</strong><br />
diagnostic performance suggest that MRCP can; (1)<br />
reliably demonstrate normal and abnormal pancreatic and<br />
biliary ducts, (2) accurately diagnose the cause and site<br />
<strong>of</strong> obstruction, (3) be <strong>of</strong> diagnostic value when ERCP is<br />
unsuccessful.<br />
ERCP cannot be performed after biliary-enteric anastomosis<br />
when the anastomosis is beyond the duedonum,<br />
as is frequently the case. Likewise, ERCP cannot be<br />
performed after gastro-enterostomy such as a Billroth 2.<br />
MRCP may be preferred to ERCP in patients with suspected<br />
solid extraductal masses, or cystic masses that<br />
do not communicate with the duct system [21] . Patient<br />
preference for non-invasive imaging may also be a consideration<br />
to perform MRCP rather than ERCP. It is likely that<br />
in the near future MRCP will replace diagnostic ERCP<br />
as the modality <strong>of</strong> choice for imaging the biliary and<br />
pancreatic ducts.<br />
REFERENCES<br />
1 Fulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM.<br />
Half-Fourier RARE MR cholangiopancreatography: experience<br />
in 300 subjects. Radiology 1998; 207: 21-32<br />
2 Guibaud L, Bret PM, Reinhold C, Atri M, Barkun AN. Bile<br />
duct obstruction and choledocholithiasis: diagnosis with MR<br />
cholangiography. Radiology 1995; 197: 109-115<br />
3 Regan F, Fradin J, Khazan R, Bohlman M, Magnuson T.<br />
Choledocholithiasis: evaluation with MR cholangiography.<br />
www.wjgnet.com
2534 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
AJR Am J Roentgenol 1996; 167: 1441-1445<br />
4 Taourel P, Bret PM, Reinhold C, Barkun AN, Atri M.<br />
Anatomic variants <strong>of</strong> the biliary tree: diagnosis with MR chola<br />
ngiopancreatography. Radiology 1996; 199: 521-527<br />
5 Hirohashi S, Hirohashi R, Uchida H, Akira M, Itoh T, Haku<br />
E, Ohishi H. Pancreatitis: evaluation with MR cholangiopancreatography<br />
in children. Radiology 1997; 203: 411-415<br />
6 Matos C, Metens T, Deviere J, Nicaise N, Braude P, Van<br />
Yperen G, Cremer M, Struyven J. Pancreatic duct: morphologic<br />
and functional evaluation with dynamic MR pancreatography<br />
after secretin stimulation. Radiology 1997; 203: 435-441<br />
7 Barish MA, Soto JA. MR cholangiopancreatography: techniques<br />
and clinical applications. AJR Am J Roentgenol 1997; 169:<br />
1295-1303<br />
8 Miyazaki T, Yamashita Y, Tsuchigame T, Yamamoto H,<br />
Urata J, Takahashi M. MR cholangiopancreatography using<br />
HASTE (half-Fourier acquisition single-shot turbo spin-echo)<br />
sequences. AJR Am J Roentgenol 1996; 166: 1297-1303<br />
9 Irie H, Honda H, Tajima T, Kuroiwa T, Yoshimitsu K,<br />
Makisumi K, Masuda K. Optimal MR cholangiopancreatogra<br />
phic sequence and its clinical application. Radiology 1998; 206:<br />
379-387<br />
10 Yamashita Y, Abe Y, Tang Y, Urata J, Sumi S, Takahashi M.<br />
In vitro and clinical studies <strong>of</strong> image acquisition in breathhold<br />
MR cholangiopancreatography: single-shot projection<br />
technique versus multislice technique. AJR Am J Roentgenol<br />
1997; 168: 1449-1454<br />
11 Fulcher AS, Turner MA, Capps GW. MR cholangiography:<br />
technical advances and clinical applications. Radiographics<br />
1999; 19: 25-41; discussion 41-44<br />
12 Fulcher AS, Turner MA. MR pancreatography: a useful tool<br />
for evaluating pancreatic disorders. Radiographics 1999; 19:<br />
5-24; discussion 41-44; quiz 148-149<br />
13 Lillemoe KD, Pitt HA, Cameron JL. Current management <strong>of</strong><br />
benign bile duct strictures. Adv Surg 1992; 25: 119-174<br />
14 Lee MG, Lee HJ, Kim MH, Kang EM, Kim YH, Lee SG, Kim<br />
PN, Ha HK, Auh YH. Extrahepatic biliary diseases: 3D MR<br />
cholangiopancreatography compared with endoscopic retrograde<br />
cholangiopancreatography. Radiology 1997; 202: 663-669<br />
15 Khalid TR, Casillas VJ, Montalvo BM, Centeno R, Levi JU.<br />
Using MR cholangiopancreatography to evaluate iatrogenic<br />
bile duct injury. AJR Am J Roentgenol 2001; 177: 1347-1352<br />
16 Vitellas KM, El-Dieb A, Vaswani K, Bennett WF, Fromkes J,<br />
Steinberg S, Bova JG. Detection <strong>of</strong> bile duct leaks using MR<br />
cholangiography with mangfodipir trisodium (Teslascan). J<br />
Comput Assist Tomogr 2001; 25: 102-105<br />
17 Bret PM, Reinhold C, Taourel P, Guibaud L, Atri M, Barkun<br />
AN. Pancreas divisum: evaluation with MR cholangiopancreat<br />
ography. Radiology 1996; 199: 99-103<br />
<strong>18</strong> Soto JA, Barish MA, Yucel EK, Clarke P, Siegenberg D, Chuttani<br />
www.wjgnet.com<br />
R, Ferrucci JT. Pancreatic duct: MR cholangiopancreatography<br />
with a three-dimensional fast spin-echo technique. Radiology<br />
1995; 196: 459-464<br />
19 Nealon WH, Townsend CM Jr, Thompson JC. Preoperative<br />
endoscopic retrograde cholangiopancreatography (ERCP) in<br />
patients with pancreatic pseudocyst associated with resolving<br />
acute and chronic pancreatitis. Ann Surg 1989; 209: 532-538;<br />
discussion 538-540<br />
20 Freeny PC, Marks WM, Ryan JA, Traverso LW. Pancreatic<br />
ductal adenocarcinoma: diagnosis and staging with dynamic<br />
CT. Radiology 1988; 166: 125-133<br />
21 Schwartz LH, Coakley FV, Sun Y, Blumgart LH, Fong Y,<br />
Panicek DM. Neoplastic pancreaticobiliary duct obstruction:<br />
evaluation with breath-hold MR cholangiopancreatography.<br />
AJR Am J Roentgenol 1998; 170: 1491-1495<br />
22 Semelka RC, Kelekis NL, John G, Ascher SM, Burdeny D,<br />
Siegelman ES. Ampullary carcinoma: demonstration by<br />
current MR techniques. J Magn Reson Imaging 1997; 7: 153-156<br />
23 Traverso LW, Peralta EA, Ryan JA Jr, Kozarek RA. Intraductal<br />
neoplasms <strong>of</strong> the pancreas. Am J Surg 1998; 175: 426-432<br />
24 Warshaw AL, Compton CC, Lewandrowski K, Cardenosa<br />
G, Mueller PR. Cystic tumors <strong>of</strong> the pancreas. New clinical,<br />
radiologic, and pathologic observations in 67 patients. Ann<br />
Surg 1990; 212: 432-443; discussion 444-445<br />
25 Fukukura Y, Fujiyoshi F, Sasaki M, Ichinari N, Inoue H, Kajiya<br />
Y, Nakajo M. HASTE MR cholangiopancreatography in the<br />
evaluation <strong>of</strong> intraductal papillary-mucinous tumors <strong>of</strong> the<br />
pancreas. J Comput Assist Tomogr 1999; 23: 301-305<br />
26 Silas AM, Morrin MM, Raptopoulos V, Keogan MT.<br />
Intraductal papillary mucinous tumors <strong>of</strong> the pancreas. AJR<br />
Am J Roentgenol 2001; 176: 179-<strong>18</strong>5<br />
27 Bradley EL 3rd, Young PR Jr, Chang MC, Allen JE, Baker<br />
CC, Meredith W, Reed L, Thomason M. Diagnosis and initial<br />
management <strong>of</strong> blunt pancreatic trauma: guidelines from a<br />
multiinstitutional review. Ann Surg 1998; 227: 861-869<br />
28 Kozarek RA, Ball TJ, Patterson DJ, Freeny PC, Ryan JA,<br />
Traverso LW. Endoscopic transpapillary therapy for<br />
disrupted pancreatic duct and peripancreatic fluid collections.<br />
<strong>Gastroenterology</strong> 1991; 100: 1362-1370<br />
29 Nirula R, Velmahos GC, Demetriades D. Magnetic resonance<br />
cholangiopancreatography in pancreatic trauma: a new<br />
diagnostic modality? J Trauma 1999; 47: 585-587<br />
30 Soto JA, Alvarez O, Munera F, Yepes NL, Sepulveda ME,<br />
Perez JM. Traumatic disruption <strong>of</strong> the pancreatic duct:<br />
diagnosis with MR pancreatography. AJR Am J Roentgenol<br />
2001; 176: 175-178<br />
31 Pavone P, Laghi A, Catalano C, Broglia L, Panebianco V, Messina<br />
A, Salvatori FM, Passariello R. MR cholangiography in the<br />
examination <strong>of</strong> patients with biliary-enteric anastomoses. AJR Am<br />
J Roentgenol 1997; 169: 807-811<br />
S- Editor Liu Y L- Editor Alpini GD E- Editor Che YB
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2535-2540<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Yusuf Bayraktar, Pr<strong>of</strong>essor, Series Editor<br />
Portal hypertension due to portal venous thrombosis:<br />
Etiology, clinical outcomes<br />
Ozgur Harmanci, Yusuf Bayraktar<br />
Ozgur Harmanci, Hacettepe University Faculty <strong>of</strong> Medicine,<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, Sihhiye 06100, Ankara, Turkey<br />
Yusuf Bayraktar, Hacettepe University Faculty <strong>of</strong> Medicine,<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, Sihhiye 06100, Ankara, Turkey<br />
Correspondence to: Ozgur Harmanci, MD, Hacettepe University<br />
Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Gastroenterology</strong>, 06100<br />
Sihhiye, Ankara, Turkey. ozgurmd@hacettepe.edu.tr<br />
Telephone: +90-312-4439428 Fax: +90-312-4429429<br />
Received: 2007-03-07 Accepted: 2007-03-12<br />
Abstract<br />
The thrombophilia in adult life has major implications in<br />
the hepatic vessels. The resulting portal vein thrombosis<br />
has various outcomes and complications. Esophageal<br />
varices, portal gastropathy, ascites, severe hypersplenism<br />
and liver failure needing liver transplantation are known<br />
well. The newly formed collateral venous circulation<br />
showing itself as pseudocholangicarcinoma sign and<br />
its possible clinical reflection as cholestasis are also<br />
known from a long time. The management strategies<br />
for these complications <strong>of</strong> portal vein thrombosis are not<br />
different from their counterpart which is cirrhotic portal<br />
hypertension, but the prognosis is unquestionably better<br />
in former cases. In this review we present and discuss the<br />
portal vein thrombosis, etiology and the resulting clinical<br />
pictures. There are controversial issues in nomenclature,<br />
management (including anticoagulation problems), follow<br />
up strategies and liver transplantation. In the light <strong>of</strong> the<br />
current knowledge, we discuss some controversial issues<br />
in literature and present our experience and our proposals<br />
about this group <strong>of</strong> patients.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Portal vein thrombosis; Pseudocholangiocarcinoma<br />
sign; Thrombophilia<br />
Harmanci O, Bayraktar Y. Portal hypertension due to portal<br />
venous thrombosis: Etiology, clinical outcomes. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2535-2540<br />
http://www.wjgnet.com/1007-9327/13/2535.asp<br />
INTRODUCTION<br />
Portal vein thrombosis (PVT) refers to total or near-<br />
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total obstruction <strong>of</strong> blood flow. This obstruction may<br />
result from invasion <strong>of</strong> primary or secondary tumors <strong>of</strong><br />
liver and thrombosis <strong>of</strong> portal vein. The obstruction may<br />
extend towards liver involving intrahepatic portal branches<br />
or may extend distally to involve splenic or mesenteric<br />
branches. In some occasions extensive involvement <strong>of</strong><br />
all <strong>of</strong> these vessels may occur with intestinal ischemia.<br />
Therefore, the involved segment <strong>of</strong> portal venous system<br />
and the degree <strong>of</strong> compensatory mechanisms determines<br />
the clinical presentation. Although PVT has been observed<br />
most commonly in the setting <strong>of</strong> cirrhosis or liver tumors,<br />
the discussion <strong>of</strong> PVT from this point highlights chronic,<br />
noncirrhotic and nontumoral PVT unless otherwise<br />
mentioned.<br />
PVT has important outcomes for the liver. On cessation<br />
<strong>of</strong> blood flow liver loses about two thirds <strong>of</strong> its blood<br />
supply. Interestingly, while acute arterial blockage usually<br />
results in severe hepatic failure or death, this condition<br />
is tolerated well and patients are almost asymptomatic<br />
because <strong>of</strong> compensatory mechanisms. First compensatory<br />
mechanism is the well-known “arterial vasodilation” <strong>of</strong><br />
the hepatic artery (which is a vascular reflex seen in every<br />
dual-vessel supplied organ) also observed during portal<br />
vein clamping in liver surgery [1] . This “arterial rescue”<br />
stabilizes the liver functions at a normal level in the acute<br />
stages <strong>of</strong> PVT. The second rescue mechanism is the<br />
“venous rescue” involving rapid development <strong>of</strong> collateral<br />
vessels to bypass the obstructed part. These vessels begin<br />
to form in few days after the obstruction and organize<br />
into a cavernomatous transformation in 3-5 wk [2,3] . This<br />
condition has acutely developing harmful effects over<br />
intestinal circulation compromising the patient’s life before<br />
development <strong>of</strong> portal hypertension and its results.<br />
Beside these compensatory mechanisms, liver bears the<br />
burden <strong>of</strong> decreased blood to a some extent. The decreased<br />
portal blood flow stimulates apoptosis in hepatocytes <strong>of</strong><br />
rats when portal vein is obliterated in a gradual fashion [4] and<br />
increases mitotic activity <strong>of</strong> hepatocytes in the unaffected<br />
lobe. The latter effect is well-known from selective<br />
presurgery portal vein obliteration performed in intent to<br />
stimulate the hypertrophy <strong>of</strong> the opposite lobe <strong>of</strong> the liver<br />
used in cancer surgery. Gradual loss <strong>of</strong> hepatic mass may<br />
be responsible for the case <strong>of</strong> mild to moderate degree <strong>of</strong><br />
hepatic synthetic dysfunction noted in advanced stages.<br />
PRevaleNCe Of PvT<br />
The prevalence <strong>of</strong> PVT in the general population was<br />
www.wjgnet.com
Harmanci O et al. Portal venous enous thrombosis<br />
thrombosis<br />
hrombosis 2537<br />
Figure 1 A case <strong>of</strong> chronic PVT in which typical cavernous transformation is<br />
observed. The computed tomography angiography <strong>of</strong> the portal vein shows<br />
intensive collaterals around portal hilus and midline abdominal structures. Portal<br />
vein is not visible and replaced by collaterals.<br />
70%, then this may signal a shortage <strong>of</strong> the tested natural<br />
anticoagulant protein significantly disproportionate to<br />
decreased synthesis <strong>of</strong> proteins from liver. This formula is<br />
easy to use in clinics and is practical to find out a possible<br />
genetic deficiency.<br />
PVT cannot be solely charged to one cause. It is now<br />
widely accepted that the PVT occurs from both a primary<br />
thrombophilic milieu and a cause that triggers the formation<br />
<strong>of</strong> the pathological thrombus in portal circulation. The<br />
aforementioned factors are considered as thrombophilic<br />
background rather than the primary etiologic reason<br />
according to multifactorial theory <strong>of</strong> thrombogenesis. The<br />
other c<strong>of</strong>actors required to develop a thrombus can be<br />
grouped as local and systemic factors most <strong>of</strong> which are<br />
potentially curable or preventable factors.<br />
DIagNOsIs<br />
The PVT can be defined as presence <strong>of</strong> portal hypertension<br />
(shown by presence <strong>of</strong> splenomegaly, esophageal or gastric<br />
varices) and identification <strong>of</strong> tubular and serpentine vascular<br />
structures resembling cavernoma at the site <strong>of</strong> hepatic hilum<br />
replacing the portal vein. This anatomical description can be<br />
made either by use <strong>of</strong> gray scale ultrasound (findings also<br />
shown by Doppler-US) and the diagnosis was confirmed<br />
by noninvasive radiological imaging techniques such as<br />
computed tomography angiography (Figure 1) ) and magnetic<br />
resonance angiography or digital splenoportography. All<br />
the patients should undergo a thorough medical evaluation<br />
including a detailed physical examination and questioning <strong>of</strong><br />
the history.<br />
ClINICal OUTCOmes<br />
The outcomes <strong>of</strong> the PVT vary from one patient to another<br />
and depend on some important factors. The condition<br />
may present itself as one <strong>of</strong> its complications. But because<br />
<strong>of</strong> lack <strong>of</strong> convincing evidence in the literature, the<br />
most common early presentation <strong>of</strong> PVT (not related to<br />
cirrhosis) is still not known. In our institutional experience,<br />
most common presentation is variceal bleeding followed by<br />
pancytopenia due to hypersplenism. Undefined cholestasis<br />
related to pseudocholangiocarcinoma sign (without icterus)<br />
is also one <strong>of</strong> the rare presentations.<br />
With the advent and wide distribution <strong>of</strong> USG and<br />
Doppler-USG, the condition is becoming diagnosed earlier<br />
and a patient presenting with ascites (which is a late finding<br />
in course <strong>of</strong> PVT) is almost not seen. Webb and Sherlock [6]<br />
reported in 1979 that out <strong>of</strong> 97 patients with PVT 13<br />
presented with ascites in a high rate (13.5%). There are still<br />
some PVT cases presenting as ascites in underdeveloped<br />
parts <strong>of</strong> the world related to absence <strong>of</strong> early diagnosis<br />
with similar rates around 13% [27] .<br />
Esophageal and gastric varices related bleeding<br />
contribute to the most important cause <strong>of</strong> morbidity<br />
and hospitalization in this group <strong>of</strong> patients. When<br />
the characteristics <strong>of</strong> variceal bleeding are considered,<br />
major differences between cirrhosis vs PVT related<br />
bleeding must be pointed out. First, the risk <strong>of</strong> variceal<br />
bleeding in cirrhosis is roughly 80-120 times more<br />
than PVT (noncirrhotic) related variceal bleeding [28-30]<br />
and esophageal varices (irrespective <strong>of</strong> size) are noted<br />
in about 90% percent <strong>of</strong> patients. Gastric varices are<br />
mostly seen concomitantly with esophageal varices<br />
in about 40% <strong>of</strong> the patients in PVT while portal<br />
gastropathy is also a rare feature <strong>of</strong> this condition [30,31] .<br />
Compared with portosystemic varices noted in cirrhotic<br />
patients, the varices in PVT patients have some special<br />
charateristics like; 1-“varice-on-varice” finding is less<br />
commonly observed, 2-the sizes <strong>of</strong> the varices are smaller,<br />
3-associated portal gastropathy is less commonly present [32] .<br />
The retrospective study (examined the determinants <strong>of</strong><br />
survival in a heterogenous group <strong>of</strong> patients including 124<br />
noncirrhotic vs 48 cirrhotic PVT cases) <strong>of</strong> Janssen et al [28]<br />
showed that either the presence <strong>of</strong> varices or bleeding<br />
episodes <strong>of</strong> varices had no impact on survival rates and<br />
the most common cause <strong>of</strong> death was malignancy related<br />
causes. Twenty four percent <strong>of</strong> the study population had<br />
malignancies like hepatocellular cancer, pancreatic cancer,<br />
or other malignancy elsewhere metastatic to the liver which<br />
presented itself in liver as PVT pointing to end stage<br />
malignancies.<br />
Although the risk <strong>of</strong> variceal bleeding is low in noncirrhotic<br />
patients, managing bleeding varices is not<br />
different from cirrhotic patients. Unfortunately there<br />
are no studies in the literature comparing endoscopic<br />
procedures vs surgical procedures in acutely bleeding<br />
varices and about the topic <strong>of</strong> primary prophylaxis.<br />
We believe that primary prophylaxis with endoscopic<br />
procedures in effort to clear varices should be applied<br />
with careful surveying and secondary prophylaxis with<br />
combination <strong>of</strong> endoscopic procedures and medical<br />
treatment despite beta-blokers may work although there is<br />
not objective and suffient evidence.<br />
In contrast, beta-blockers may result in more sluggish<br />
portal flow as is same issue for nitrates and terlipressin<br />
increasing the risk <strong>of</strong> progression <strong>of</strong> thrombosis and even<br />
worsening <strong>of</strong> portal hypertension. This decision must be<br />
adjusted with the patient’s condition rather than a standart<br />
medical care.<br />
One interesting and misleading clinical condition<br />
that may occur during the course <strong>of</strong> the PVT is<br />
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“pseudocholangiocarcinoma sign” (PSCS). After the<br />
obstruction in the portal system, the “venous rescue”<br />
begins to occur immediately which takes time about 5 wk [2]<br />
forming new vessels around intrahepatic, extrahepatic<br />
biliary tracts and around gallbladder (majorly, vascular<br />
plexus <strong>of</strong> Saint and Petren enlarge and dilate to become<br />
large serpentine vessels) named as “portal cavernomatous<br />
transformation”. Sometimes these vessels can be small<br />
in caliber to visualize depending on the extent <strong>of</strong> portal<br />
flow and capacity <strong>of</strong> new vessel formation, but if a careful<br />
ERCP is performed the direct effects <strong>of</strong> these vessels over<br />
biliary ducts or main bile duct as strictures, displacements,<br />
thumprinting effects or irregularity can be seen in at<br />
least 80% <strong>of</strong> the patients [30] . This condition mimics a<br />
cholangiocellular cancer in ERCP and therefore called<br />
PSCS [32,33] .<br />
The clinical impact <strong>of</strong> these changes results in a wide<br />
spectrum <strong>of</strong> findings ranging from normal biochemical<br />
and physical findings to overt cholestasis with increased<br />
cholestatic enzymes and liver injury (rarely observed).<br />
Although a the term called “portal biliopathy” and a<br />
classification system is proposed [34] we believe that this<br />
term and classification system are impracticable to use<br />
because; (1) ) new collaterals form depending on the site<br />
and level <strong>of</strong> portal vein obstruction, (2) ) wide range <strong>of</strong><br />
anatomical variations between human beings in this<br />
anatomical site resulting in different types <strong>of</strong> cavernous<br />
transformations, (3) ) the nature <strong>of</strong> new vessel formation<br />
is unpredictable and not standart in all portal vein<br />
thrombosis patients, d) the classification system does<br />
not have impact over treatment or follow up strategy.<br />
We propose that only defining the presence or absence<br />
<strong>of</strong> PSCS is a satisfactory practice not to complicate the<br />
picture further because the clinically obvious cholestasis<br />
or jaundice is observed in only about 5% [35] . Therefore<br />
this physiological compensatory response is not a “-pathy”<br />
but just an adaptive change with a low degree <strong>of</strong> clinical<br />
importance.<br />
The clinically obvious cholestasis either presenting<br />
itself as repeating biliary stones or cholangitis or liver<br />
injury can be treated with conventional methods including<br />
stenting, papillotomy or even surgery.<br />
Hypersplenism is a finding <strong>of</strong> latent or chronic PVT<br />
cases and this complication is important when anticoagulation<br />
treatment is considered. Hypersplenism is<br />
almost always present except in the rare patient with a<br />
partial thrombus in one branch <strong>of</strong> the portal vein with<br />
the other branch remained intact presenting with a mild<br />
degree <strong>of</strong> portal hypertension. The levels <strong>of</strong> all blood<br />
elements begin to decrease as the condition worsens and<br />
severe hypersplenism is now considered one <strong>of</strong> the most<br />
important indications in this group <strong>of</strong> patients to undergo<br />
a shunt surgery combined with or without a splenectomy.<br />
In the clinical setting <strong>of</strong> hypersplenism with low platelet<br />
counts combined with esophageal varices raises concerns<br />
about the safety <strong>of</strong> anticoagulation. Unfortunately, the<br />
literature lacks information about the safety and long-term<br />
results <strong>of</strong> anticoagulation in well designed prospective<br />
controlled studies. A study to clarify this controversial<br />
topic was a retrospective analysis. In this study [29] Condat<br />
et al included 136 PVT patients in whom 84 was receiving<br />
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anticoagulant treatment. The study has some limits like<br />
heterogenous groups (pretreatment endoscopies <strong>of</strong> all<br />
patients and standardization <strong>of</strong> a homogeneous varice<br />
distribution between two groups is not carried out) and<br />
lack <strong>of</strong> information about comorbid conditions <strong>of</strong> the<br />
engaging patients, but the study has a low statistical<br />
degree <strong>of</strong> evidence to favor anticoagulation treatment.<br />
Anticoagulation was not found to be a risk factor for<br />
bleeding in this study while nonanticoagulation resulted<br />
in more thrombotic recurrences as expected. From our<br />
institutional experience, we believe that it may be a good<br />
practice to select patients according to their co-morbid<br />
conditions, degree <strong>of</strong> hypersplenism (low platelet counts<br />
may be a relative contraindication for anticoagulation) and<br />
the condition <strong>of</strong> varices (eradication combined with or<br />
without medical prophylaxis before start <strong>of</strong> treatment may<br />
be considered to decrese bleeding related risks).<br />
lIveR TRaNsPlaNTaTION IN PvT<br />
Previously (during the 1990s) PVT was an established<br />
contrain-dication for liver transplantation. But this myth<br />
has been vanished with great innovations in both medicalsurgical<br />
care and radiological interventions. Currently,<br />
chronic PVT itself may present as an indication for liver<br />
transplantation because <strong>of</strong> synthetic failure <strong>of</strong> liver.<br />
Although either living donor liver transplanation (LDLT)<br />
and deceased donor liver transplantation (DDLT) can be<br />
performed, it is the experience and ability <strong>of</strong> the medical<br />
care center that should make the final decision about the<br />
type <strong>of</strong> transplantation. In various studies [36-41] it has been<br />
shown that both surgical techniques (thrombectomy,<br />
thromboendvenectomy with venous reconstruction,<br />
interposition <strong>of</strong> vein graft, porto-caval hemitransposition<br />
and others) and radiological endovascular interventions can<br />
be used to overcome venous obstruction in the recipient [42] .<br />
A major drawback about these studies is that most <strong>of</strong> the<br />
patient population is formed <strong>of</strong> PVT patients who had<br />
underlying cirrhosis or hepatocellular cancer. Noncirrhotic<br />
and nonmalignant chronic PVT patients form a minority.<br />
CONClUsION<br />
We need further studies to outline and describe the indications<br />
for liver transplantation in this patient population.<br />
Also it is essential to form universal anatomical classification<br />
system <strong>of</strong> PVT for a standard language in literature.<br />
In this regard, the system proposed by Yerdel et al [43]<br />
can be suggested.<br />
RefeReNCes<br />
1 Henderson JM, Gilmore GT, Mackay GJ, Galloway JR, Dodson<br />
TF, Kutner MH. Hemodynamics during liver transplantation:<br />
the interactions between cardiac output and portal venous and<br />
hepatic arterial flows. Hepatology 1992; 16: 715-7<strong>18</strong><br />
2 Ohnishi K, Okuda K, Ohtsuki T, Nakayama T, Hiyama Y,<br />
Iwama S, Goto N, Nakajima Y, Musha N, Nakashima T.<br />
Formation <strong>of</strong> hilar collaterals or cavernous transformation<br />
after portal vein obstruction by hepatocellular carcinoma.<br />
Observations in ten patients. <strong>Gastroenterology</strong> 1984; 87: 1150-1153<br />
3 De Gaetano AM, Lafortune M, Patriquin H, De Franco A,<br />
Aubin B, Paradis K. Cavernous transformation <strong>of</strong> the portal
Harmanci O et al. Portal venous enous thrombosis<br />
thrombosis<br />
hrombosis 2539<br />
vein: patterns <strong>of</strong> intrahepatic and splanchnic collateral<br />
circulation detected with Doppler sonography. AJR Am J<br />
Roentgenol 1995; 165: 1151-1155<br />
4 Ogren M, Bergqvist D, Wahlander K, Eriksson H, Sternby NH.<br />
Trousseau's syndrome-what is the evidence? A populationbased<br />
autopsy study. Thromb Haemost 2006; 95: 541-545<br />
5 Bilodeau M, Aubry MC, Houle R, Burnes PN, Ethier C.<br />
Evaluation <strong>of</strong> hepatocyte injury following partial ligation <strong>of</strong><br />
the left portal vein. J Hepatol 1999; 30: 29-37<br />
6 Webb LJ, Sherlock S. The aetiology, presentation and natural<br />
history <strong>of</strong> extra-hepatic portal venous obstruction. Q J Med<br />
1979; 48: 627-639<br />
7 Cardin F, Graffeo M, McCormick PA, McIntyre N, Burroughs<br />
A. Adult "idiopathic" extrahepatic venous thrombosis.<br />
Importance <strong>of</strong> putative "latent" myeloproliferative disorders<br />
and comparison with cases with known etiology. Dig Dis Sci<br />
1992; 37: 335-339<br />
8 Stringer MD, Heaton ND, Karani J, Olliff S, Howard ER.<br />
Patterns <strong>of</strong> portal vein occlusion and their aetiological<br />
significance. Br J Surg 1994; 81: 1328-1331<br />
9 Orozco H, Takahashi T, Mercado MA, Prado E, Chan C.<br />
Surgical management <strong>of</strong> extrahepatic portal hypertension and<br />
variceal bleeding. <strong>World</strong> J Surg 1994; <strong>18</strong>: 246-250<br />
10 Orl<strong>of</strong>f MJ, Orl<strong>of</strong>f MS, Rambotti M. Treatment <strong>of</strong> bleeding<br />
esophagogastric varices due to extrahepatic portal hypertension:<br />
results <strong>of</strong> portal-systemic shunts during 35 years. J Pediatr Surg<br />
1994; 29: 142-151; discussion 151-154<br />
11 Vleggaar FP, van Buuren HR, Schalm SW. Endoscopic<br />
sclerotherapy for bleeding oesophagogastric varices secondary<br />
to extrahepatic portal vein obstruction in an adult Caucasian<br />
population. Eur J Gastroenterol Hepatol 1998; 10: 81-85<br />
12 Denninger MH, Chait Y, Casadevall N, Hillaire S, Guillin<br />
MC, Bezeaud A, Erlinger S, Briere J, Valla D. Cause <strong>of</strong> portal<br />
or hepatic venous thrombosis in adults: the role <strong>of</strong> multiple<br />
concurrent factors. Hepatology 2000; 31: 587-591<br />
13 Valla D, Casadevall N, Huisse MG, Tulliez M, Grange JD,<br />
Muller O, Binda T, Varet B, Rueff B, Benhamou JP. Etiology <strong>of</strong><br />
portal vein thrombosis in adults. A prospective evaluation <strong>of</strong><br />
primary myeloproliferative disorders. <strong>Gastroenterology</strong> 1988;<br />
94: 1063-1069<br />
14 Valla D, Casadevall N, Lacombe C, Varet B, Goldwasser<br />
E, Franco D, Maillard JN, Pariente EA, Leporrier M, Rueff<br />
B. Primary myeloproliferative disorder and hepatic vein<br />
thrombosis. A prospective study <strong>of</strong> erythroid colony formation<br />
in vitro in 20 patients with Budd-Chiari syndrome. Ann Intern<br />
Med 1985; 103: 329-334<br />
15 Valla DC, Condat B. Portal vein thrombosis in adults:<br />
pathophysiology, pathogenesis and management. J Hepatol<br />
2000; 32: 865-871<br />
16 De Stefano V, Te<strong>of</strong>ili L, Leone G, Michiels JJ. Spontaneous<br />
erythroid colony formation as the clue to an underlying<br />
myeloproliferative disorder in patients with Budd-Chiari<br />
syndrome or portal vein thrombosis. Semin Thromb Hemost<br />
1997; 23: 411-4<strong>18</strong><br />
17 Baxter EJ, Scott LM, Campbell PJ, East C, Fourouclas N,<br />
Swanton S, Vassiliou GS, Bench AJ, Boyd EM, Curtin N, Scott<br />
MA, Erber WN, Green AR. Acquired mutation <strong>of</strong> the tyrosine<br />
kinase JAK2 in human myeloproliferative disorders. Lancet<br />
2005; 365: 1054-1061<br />
<strong>18</strong> James C, Ugo V, Le Couedic JP, Staerk J, Delhommeau F,<br />
Lacout C, Garcon L, Raslova H, Berger R, Bennaceur-Griscelli<br />
A, Villeval JL, Constantinescu SN, Casadevall N, Vainchenker<br />
W. A unique clonal JAK2 mutation leading to constitutive<br />
signalling causes polycythaemia vera. Nature 2005; 434:<br />
1144-1148<br />
19 Kralovics R, Passamonti F, Buser AS, Teo SS, Tiedt R, Passweg<br />
JR, Tichelli A, Cazzola M, Skoda RC. A gain-<strong>of</strong>-function<br />
mutation <strong>of</strong> JAK2 in myeloproliferative disorders. N Engl J<br />
Med 2005; 352: 1779-1790<br />
20 Colaizzo D, Amitrano L, Tiscia GL, Scenna G, Grandone E,<br />
Guardascione MA, Brancaccio V, Margaglione M. The JAK2<br />
V617F mutation frequently occurs in patients with portal<br />
and mesenteric venous thrombosis. J Thromb Haemost 2007; 5:<br />
55-61<br />
21 Primignani M, Barosi G, Bergamaschi G, Gianelli U, Fabris F,<br />
Reati R, Dell'Era A, Bucciarelli P, Mannucci PM. Role <strong>of</strong> the<br />
JAK2 mutation in the diagnosis <strong>of</strong> chronic myeloproliferative<br />
disorders in splanchnic vein thrombosis. Hepatology 2006; 44:<br />
1528-1534<br />
22 Mack CL, Superina RA, Whitington PF. Surgical restoration <strong>of</strong><br />
portal flow corrects procoagulant and anticoagulant deficiencies<br />
associated with extrahepatic portal vein thrombosis. J Pediatr<br />
2003; 142: 197-199<br />
23 Dubuisson C, Boyer-Neumann C, Wolf M, Meyer D, Bernard<br />
O. Protein C, protein S and antithrombin III in children with<br />
portal vein obstruction. J Hepatol 1997; 27: 132-135<br />
24 Fisher NC, Wilde JT, Roper J, Elias E. Deficiency <strong>of</strong> natural<br />
anticoagulant proteins C, S, and antithrombin in portal vein<br />
thrombosis: a secondary phenomenon? Gut 2000; 46: 534-539<br />
25 Pabinger I, Allaart CF, Hermans J, Briet E, Bertina RM.<br />
Hereditary protein C-deficiency: laboratory values in<br />
transmitters and guidelines for the diagnostic procedure.<br />
Report on a study <strong>of</strong> the SSC Subcommittee on Protein C and<br />
Protein S. Protein C Transmitter Study Group. Thromb Haemost<br />
1992; 68: 470-474<br />
26 Janssen HL, Meinardi JR, Vleggaar FP, van Uum SH,<br />
Haagsma EB, van Der Meer FJ, van Hattum J, Chamuleau RA,<br />
Adang RP, Vandenbroucke JP, van Hoek B, Rosendaal FR.<br />
Factor V Leiden mutation, prothrombin gene mutation, and<br />
deficiencies in coagulation inhibitors associated with Budd-<br />
Chiari syndrome and portal vein thrombosis: results <strong>of</strong> a casecontrol<br />
study. Blood 2000; 96: 2364-2368<br />
27 Sarin SK, Aggarwal SR. Idiopathic portal hypertension.<br />
Digestion 1998; 59: 420-423<br />
28 Janssen HL, Wijnhoud A, Haagsma EB, van Uum SH, van<br />
Nieuwkerk CM, Adang RP, Chamuleau RA, van Hattum<br />
J, Vleggaar FP, Hansen BE, Rosendaal FR, van Hoek B.<br />
Extrahepatic portal vein thrombosis: aetiology and determinants<br />
<strong>of</strong> survival. Gut 2001; 49: 720-724<br />
29 Condat B, Pessione F, Hillaire S, Denninger MH, Guillin<br />
MC, Poliquin M, Hadengue A, Erlinger S, Valla D. Current<br />
outcome <strong>of</strong> portal vein thrombosis in adults: risk and benefit<br />
<strong>of</strong> anticoagulant therapy. <strong>Gastroenterology</strong> 2001; 120: 490-497<br />
30 Sarin SK, Agarwal SR. Extrahepatic portal vein obstruction.<br />
Semin Liver Dis 2002; 22: 43-58<br />
31 Bayraktar Y, Balkanci F, Uzunalimoglu B, Gokoz A, Koseoglu<br />
T, Batman F, Gurakar A, Van Thiel DH, Kayhan B. Is portal<br />
hypertension due to liver cirrhosis a major factor in the<br />
development <strong>of</strong> portal hypertensive gastropathy? Am J<br />
Gastroenterol 1996; 91: 554-558<br />
32 Bayraktar Y, Balkanci F, Kayhan B, Ozenc A, Arslan S, Telatar<br />
H. Bile duct varices or "pseudo-cholangiocarcinoma sign" in<br />
portal hypertension due to cavernous transformation <strong>of</strong> the<br />
portal vein. Am J Gastroenterol 1992; 87: <strong>18</strong>01-<strong>18</strong>06<br />
33 Bayraktar Y, Balkanci F, Ozenc A, Arslan S, Koseoglu T,<br />
Ozdemir A, Uzunalimoglu B, Telatar H, Gurakar A, Van Thiel<br />
DH. The "pseudo-cholangiocarcinoma sign" in patients with<br />
cavernous transformation <strong>of</strong> the portal vein and its effect on<br />
the serum alkaline phosphatase and bilirubin levels. Am J<br />
Gastroenterol 1995; 90: 2015-2019<br />
34 Chandra R, Kapoor D, Tharakan A, Chaudhary A, Sarin SK.<br />
Portal biliopathy. J Gastroenterol Hepatol 2001; 16: 1086-1092<br />
35 Dilawari JB, Chawla YK. Pseudosclerosing cholangitis in<br />
extrahepatic portal venous obstruction. Gut 1992; 33: 272-276<br />
36 Manzanet G, Sanjuan F, Orbis P, Lopez R, Moya A, Juan<br />
M, Vila J, Asensi J, Sendra P, Ruiz J, Prieto M, Mir J. Liver<br />
transplantation in patients with portal vein thrombosis. Liver<br />
Transpl 2001; 7: 125-131<br />
37 Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C,<br />
Henry L, Boillot O. Eversion thrombectomy for portal vein<br />
thrombosis during liver transplantation. Am J Transplant 2002;<br />
2: 934-938<br />
38 Gerunda GE, Merenda R, Neri D, Angeli P, Barbazza F, Valmasoni<br />
M, Feltracco P, Zangrandi F, Gangemi A, Miotto D, Gagliesi A,<br />
www.wjgnet.com
2540 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Faccioli AM. Cavoportal hemitransposition: a successful way to<br />
overcome the problem <strong>of</strong> total portosplenomesenteric thrombosis<br />
in liver transplantation. Liver Transpl 2002; 8: 72-75<br />
39 Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung<br />
G, Marubashi S, Sanchez EQ, Gogel B, Levy MF, Goldstein<br />
RM, Fasola CG, Elliott EE, Bursac N, Mulligan D, Gonwa TA,<br />
Klintmalm GB. Thrombendvenectomy for organized portal<br />
vein thrombosis at the time <strong>of</strong> liver transplantation. Ann Surg<br />
2002; 235: 292-296<br />
40 Egawa H, Tanaka K, Kasahara M, Takada Y, Oike F, Ogawa K,<br />
Sakamoto S, Kozaki K, Taira K, Ito T. Single center experience <strong>of</strong> 39<br />
patients with preoperative portal vein thrombosis among 404 adult<br />
living donor liver transplantations. Liver Transpl 2006; 12: 1512-15<strong>18</strong><br />
www.wjgnet.com<br />
41 Selvaggi G, Weppler D, Nishida S, Moon J, Levi D, Kato T, Tzakis<br />
AG. Ten-year experience in porto-caval hemitransposition for<br />
liver transplantation in the presence <strong>of</strong> portal vein thrombosis.<br />
Am J Transplant 2007; 7: 454-460<br />
42 Gomez-Gutierrez M, Quintela J, Marini M, Gala B, Suarez<br />
F, Cao I, Selles CC, Aguirrezabalaga J, Otero A, Mosteiro S.<br />
Portal vein thrombosis in patients undergoing orthotopic<br />
liver transplantation: intraoperative endovascular radiological<br />
procedures. Transplant Proc 2005; 37: 3906-3908<br />
43 Yerdel MA, Gunson B, Mirza D, Karayalcin K, Olliff S, Buckels<br />
J, Mayer D, McMaster P, Pirenne J. Portal vein thrombosis in<br />
adults undergoing liver transplantation: risk factors, screening,<br />
management, and outcome. Transplantation 2000; 69: <strong>18</strong>73-<strong>18</strong>81<br />
S- Editor Wang J L- Editor Kremer M E- Editor Wang HF
Özen H. . Glycogen storage diseases 2549<br />
AL, Sly WS, Vale D, Childs B, Kinzler KW, Vogelstein B. The<br />
metabolic & molecular basis <strong>of</strong> inherited diseases. New York:<br />
McGraw-Hill, 2001: 1521-1552<br />
5 Lewis GM, Spencer-Peet J, Stewart KM. Infantile hypoglycaemia<br />
due to inherited deficiency <strong>of</strong> glycogen synthetase in liver. Arch<br />
Dis Child 1963; 38: 40-48<br />
6 Orho M, Bosshard NU, Buist NR, Gitzelmann R, Aynsley-<br />
Green A, Blumel P, Gannon MC, Nuttall FQ, Groop LC.<br />
Mutations in the liver glycogen synthase gene in children with<br />
hypoglycemia due to glycogen storage disease type 0. J Clin<br />
Invest 1998; 102: 507-515<br />
7 Laberge AM, Mitchell GA, van de Werve G, Lambert M.<br />
Long-term follow-up <strong>of</strong> a new case <strong>of</strong> liver glycogen synthase<br />
deficiency. Am J Med Genet A 2003; 120: 19-22<br />
8 Weinstein DA, Correia CE, Saunders AC, Wolfsdorf JI.<br />
Hepatic glycogen synthase deficiency: an infrequently<br />
recognized cause <strong>of</strong> ketotic hypoglycemia. Mol Genet Metab<br />
2006; 87: 284-288<br />
9 Bachrach BE, Weinstein DA, Orho-Melander M, Burgess A,<br />
Wolfsdorf JI. Glycogen synthase deficiency (glycogen storage<br />
disease type 0) presenting with hyperglycemia and glucosuria:<br />
report <strong>of</strong> three new mutations. J Pediatr 2002; 140: 781-783<br />
10 van Schaftingen E, Gerin I. The glucose-6-phosphatase<br />
system. Biochem J 2002; 362: 513-532<br />
11 Ekstein J, Rubin BY, Anderson SL, Weinstein DA, Bach<br />
G, Abeliovich D, Webb M, Risch N. Mutation frequencies<br />
for glycogen storage disease Ia in the Ashkenazi Jewish<br />
population. Am J Med Genet A 2004; 129: 162-164<br />
12 CORI GT, CORI CF. Glucose-6-phosphatase <strong>of</strong> the liver in<br />
glycogen storage disease. J Biol Chem 1952; 199: 661-667<br />
13 Brody LC, Abel KJ, Castilla LH, Couch FJ, McKinley DR, Yin G,<br />
Ho PP, Merajver S, Chandrasekharappa SC, Xu J. Construction<br />
<strong>of</strong> a transcription map surrounding the BRCA1 locus <strong>of</strong><br />
human chromosome 17. Genomics 1995; 25: 238-247<br />
14 Lei KJ, Pan CJ, Shelly LL, Liu JL, Chou JY. Identification <strong>of</strong><br />
mutations in the gene for glucose-6-phosphatase, the enzyme<br />
deficient in glycogen storage disease type 1a. J Clin Invest 1994;<br />
93: 1994-1999<br />
15 Yang Chou J, Mansfield BC. Molecular Genetics <strong>of</strong> Type 1<br />
Glycogen Storage Diseases. Trends Endocrinol Metab 1999; 10:<br />
104-113<br />
16 Lei KJ, Pan CJ, Shelly LL, Liu JL, Chou JY. Identification <strong>of</strong><br />
mutations in the gene for glucose-6-phosphatase, the enzyme<br />
deficient in glycogen storage disease type 1a. J Clin Invest 1994;<br />
93: 1994-1999<br />
17 Rake JP, Visser G, Labrune P, Leonard JV, Ullrich K, Smit<br />
GP. Glycogen storage disease type I: diagnosis, management,<br />
clinical course and outcome. Results <strong>of</strong> the European Study on<br />
Glycogen Storage Disease Type I (ESGSD I). Eur J Pediatr 2002;<br />
161 Suppl 1: S20-S34<br />
<strong>18</strong> Rake JP, Visser G, Labrune P, Leonard JV, Ullrich K, Smit GP.<br />
Guidelines for management <strong>of</strong> glycogen storage disease type I<br />
- European Study on Glycogen Storage Disease Type I (ESGSD<br />
I). Eur J Pediatr 2002; 161 Suppl 1: S112-S119<br />
19 Visser G, Rake JP, Kokke FT, Nikkels PG, Sauer PJ, Smit GP.<br />
Intestinal function in glycogen storage disease type I. J Inherit<br />
Metab Dis 2002; 25: 261-267<br />
20 Pabuccuoglu A, Aydogdu S, Bas M. Serum biotinidase<br />
activity in children with chronic liver disease and its clinical<br />
significance. J Pediatr Gastroenterol Nutr 2002; 34: 59-62<br />
21 Saltik IN, Ozen H, Kocak N, Yuce A, Gurakan F. High<br />
biotinidase activity in type Ia glycogen storage disease. Am J<br />
Gastroenterol 2000; 95: 2144<br />
22 Burlina AB, Dermikol M, Mantau A, Piovan S, Grazian L,<br />
Zacchello F, Shin Y. Increased plasma biotinidase activity in<br />
patients with glycogen storage disease type Ia: effect <strong>of</strong> biotin<br />
supplementation. J Inherit Metab Dis 1996; 19: 209-212<br />
23 Gogus S, Kocak N, Ciliv G, Karabulut E, Akcoren Z, Kale G,<br />
Caglar M. Histologic features <strong>of</strong> the liver in type Ia glycogen<br />
storage disease: comparative study between different age<br />
groups and consecutive biopsies. Pediatr Dev Pathol 2002; 5:<br />
299-304<br />
24 Smit GP. The long-term outcome <strong>of</strong> patients with glycogen<br />
storage disease type Ia. Eur J Pediatr 1993; 152 Suppl 1: S52-S55<br />
25 Talente GM, Coleman RA, Alter C, Baker L, Brown BI,<br />
Cannon RA, Chen YT, Crigler JF Jr, Ferreira P, Haworth JC,<br />
Herman GE, Issenman RM, Keating JP, Linde R, Roe TF,<br />
Senior B, Wolfsdorf JI. Glycogen storage disease in adults. Ann<br />
Intern Med 1994; 120: 2<strong>18</strong>-226<br />
26 Chen YT, Coleman RA, Scheinman JI, Kolbeck PC, Sidbury JB.<br />
Renal disease in type I glycogen storage disease. N Engl J Med<br />
1988; 3<strong>18</strong>: 7-11<br />
27 Lin CC, Tsai JD, Lin SP, Lee HC. Renal sonographic findings<br />
<strong>of</strong> type I glycogen storage disease in infancy and early<br />
childhood. Pediatr Radiol 2005; 35: 786-791<br />
28 Restaino I, Kaplan BS, Stanley C, Baker L. Nephrolithiasis,<br />
hypocitraturia, and a distal renal tubular acidification defect in<br />
type 1 glycogen storage disease. J Pediatr 1993; 122: 392-396<br />
29 Reitsma-Bierens WC. Renal complications in glycogen storage<br />
disease type I. Eur J Pediatr 1993; 152 Suppl 1: S60-S62<br />
30 Cabrera-Abreu J, Crabtree NJ, Elias E, Fraser W, Cramb R,<br />
Alger S. Bone mineral density and markers <strong>of</strong> bone turnover<br />
in patients with glycogen storage disease types I, III and IX. J<br />
Inherit Metab Dis 2004; 27: 1-9<br />
31 Miller JH, Gates GF, Landing BH, Kogut MD, Roe TF.<br />
Scintigraphic abnormalities in glycogen storage disease. J Nucl<br />
Med 1978; 19: 354-358<br />
32 Zangeneh F, Limbeck GA, Brown BI, Emch JR, Arcasoy MM,<br />
Goldenberg VE, Kelley VC. Hepatorenal glycogenosis (type<br />
I glycogenosis) and carcinoma <strong>of</strong> the liver. J Pediatr 1969; 74:<br />
73-83<br />
33 Fraumeni JF Jr, Rosen PJ, Hull EW, Barth RF, Shapiro SR,<br />
O'Connor JF. Hepatoblastoma in infant sisters. Cancer 1969; 24:<br />
1086-1090<br />
34 Lee P, Mather S, Owens C, Leonard J, Dicks-Mireaux C.<br />
Hepatic ultrasound findings in the glycogen storage diseases.<br />
Br J Radiol 1994; 67: 1062-1066<br />
35 Franco LM, Krishnamurthy V, Bali D, Weinstein DA, Arn P,<br />
Clary B, Boney A, Sullivan J, Frush DP, Chen YT, Kishnani PS.<br />
Hepatocellular carcinoma in glycogen storage disease type Ia:<br />
a case series. J Inherit Metab Dis 2005; 28: 153-162<br />
36 Bianchi L. Glycogen storage disease I and hepatocellular<br />
tumours. Eur J Pediatr 1993; 152 Suppl 1: S63-S70<br />
37 Trioche P, Francoual J, Capel L, Odievre M, Lindenbaum<br />
A, Labrune P. Apolipoprotein E polymorphism and serum<br />
concentrations in patients with glycogen storage disease type<br />
Ia. J Inherit Metab Dis 2000; 23: 107-112<br />
38 Muhlhausen C, Schneppenheim R, Budde U, Merkel M,<br />
Muschol N, Ullrich K, Santer R. Decreased plasma concentration<br />
<strong>of</strong> von Willebrand factor antigen (VWF:Ag) in patients with<br />
glycogen storage disease type Ia. J Inherit Metab Dis 2005; 28:<br />
945-950<br />
39 Hutton RA, Macnab AJ, Rivers RP. Defect <strong>of</strong> platelet function<br />
associated with chronic hypoglycaemia. Arch Dis Child 1976;<br />
51: 49-55<br />
40 Wittenstein B, Klein M, Finckh B, Ullrich K, Kohlschutter A.<br />
Radical trapping in glycogen storage disease 1a. Eur J Pediatr<br />
2002; 161 Suppl 1: S70-S74<br />
41 Wittenstein B, Klein M, Finckh B, Ullrich K, Kohlschutter<br />
A. Plasma antioxidants in pediatric patients with glycogen<br />
storage disease, diabetes mellitus, and hypercholesterolemia.<br />
Free Radic Biol Med 2002; 33: 103-110<br />
42 Melis D, Parenti G, Della Casa R, Sibilio M, Romano A, Di<br />
Salle F, Elefante R, Mansi G, Santoro L, Perretti A, Paludetto<br />
R, Sequino L, Andria G. Brain damage in glycogen storage<br />
disease type I. J Pediatr 2004; 144: 637-642<br />
43 Ryan IP, Havel RJ, Laros RK Jr. Three consecutive pregnancies<br />
in a patient with glycogen storage disease type IA (von<br />
Gierke's disease). Am J Obstet Gynecol 1994; 170: 1687-1690;<br />
discussion 1690-1691<br />
44 Lei KJ, Chen YT, Chen H, Wong LJ, Liu JL, McConkie-Rosell<br />
A, Van Hove JL, Ou HC, Yeh NJ, Pan LY. Genetic basis <strong>of</strong><br />
glycogen storage disease type 1a: prevalent mutations at the<br />
glucose-6-phosphatase locus. Am J Hum Genet 1995; 57: 766-771<br />
45 Huner G, Podskarbi T, Schutz M, Baykal T, Sarbat G, Shin YS,<br />
Demirkol M. Molecular aspects <strong>of</strong> glycogen storage disease<br />
www.wjgnet.com
2550 ISS� 1007-9327 C� 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 �umber <strong>18</strong><br />
type Ia in Turkish patients: a novel mutation in the glucose-6phosphatase<br />
gene. J Inherit Metab Dis 1998; 21: 445-446<br />
46 Terzioglu M, Emre S, Ozen H, Saltik IN, Kocak N, Ciliv G,<br />
Yuce A, Gurakan F. Glucose-6-phosphatase gene mutations<br />
in Turkish patients with glycogen storage disease type Ia. J<br />
Inherit Metab Dis 2001; 24: 881-882<br />
47 Duarte IF, Goodfellow BJ, Barros A, Jones JG, Barosa C, Diogo<br />
L, Garcia P, Gil AM. Metabolic characterisation <strong>of</strong> plasma in<br />
juveniles with glycogen storage disease type 1a (GSD1a) by<br />
high-resolution (1)H NMR spectroscopy. NMR Biomed 2006;<br />
20: 401-412<br />
48 Qu Y, Abdenur JE, Eng CM, Desnick RJ. Molecular prenatal<br />
diagnosis <strong>of</strong> glycogen storage disease type Ia. Prenat Diagn<br />
1996; 16: 333-336<br />
49 Chen YT, Cornblath M, Sidbury JB. Cornstarch therapy in type<br />
I glycogen-storage disease. N Engl J Med 1984; 310: 171-175<br />
50 Lee PJ, Dixon MA, Leonard JV. Uncooked cornstarch--efficacy<br />
in type I glycogenosis. Arch Dis Child 1996; 74: 546-547<br />
51 Milla PJ, Atherton DA, Leonard JV, Wolff OH, Lake BD.<br />
Disordered intestinal function in glycogen storage disease. J<br />
Inherit Metab Dis 1978; 1: 155-157<br />
52 Pears J, Jung RT, Jankowski J, Waddell ID, Burchell A.<br />
Glucose-6-phosphatase in normal adult human intestinal<br />
mucosa. Clin Sci (Lond) 1992; 83: 683-687<br />
53 Bodamer OA, Feillet F, Lane RE, Lee PJ, Dixon MA, Halliday<br />
D, Leonard JV. Utilization <strong>of</strong> cornstarch in glycogen storage<br />
disease type Ia. Eur J Gastroenterol Hepatol 2002; 14: 1251-1256<br />
54 Ozen H, Ciliv G, Kocak N, Saltik IN, Yuce A, Gurakan F.<br />
Short-term effect <strong>of</strong> captopril on microalbuminuria in children<br />
with glycogen storage disease type Ia. J Inherit Metab Dis 2000;<br />
23: 459-463<br />
55 Gianni ML, Bonvissuto M, Gallieni M, Testolin C, Racchi E,<br />
Riva E. Ramipril treatment in a patient with glycogen storage<br />
disease I non-A. J Inherit Metab Dis 2002; 25: 515-516<br />
56 Baker L, Kern EFO, Olshan J, Goldfarb S, Dahlem ST. Pilot<br />
study <strong>of</strong> captopril in patients with renal disease associated<br />
with glycogen storage disease type I (GSDI). Pediatr Res 1988;<br />
23: 388A<br />
57 Nu<strong>of</strong>fer JM, Mullis PE, Wiesmann UN. Treatment with lowdose<br />
diazoxide in two growth-retarded prepubertal girls with<br />
glycogen storage disease type Ia resulted in catch-up growth. J<br />
Inherit Metab Dis 1997; 20: 790-798<br />
58 Koeberl DD, Kishnani PS, Chen YT. Glycogen storage disease<br />
types I and II: treatment updates. J Inherit Metab Dis 2007; 30:<br />
159-164<br />
59 Faivre L, Houssin D, Valayer J, Brouard J, Hadchouel M,<br />
Bernard O. Long-term outcome <strong>of</strong> liver transplantation in<br />
patients with glycogen storage disease type Ia. J Inherit Metab<br />
Dis 1999; 22: 723-732<br />
60 Liu PP, de Villa VH, Chen YS, Wang CC, Wang SH, Chiang YC,<br />
Jawan B, Cheung HK, Cheng YF, Huang TL, Eng HL, Chuang<br />
FR, Chen CL. Outcome <strong>of</strong> living donor liver transplantation for<br />
glycogen storage disease. Transplant Proc 2003; 35: 366-368<br />
61 Matern D, Starzl TE, Arnaout W, Barnard J, Bynon JS, Dhawan<br />
A, Emond J, Haagsma EB, Hug G, Lachaux A, Smit GP, Chen<br />
YT. Liver transplantation for glycogen storage disease types I,<br />
III, and IV. Eur J Pediatr 1999; 158 Suppl 2: S43-S48<br />
62 Emmett M, Narins RG. Renal tranplantation in type 1<br />
glycogenosis. Failure to improve glucose metabolism. JAMA<br />
1978; 239: 1642-1644<br />
63 Senior B, Loridan L. Functional differentiation <strong>of</strong> glycogenoses<br />
<strong>of</strong> the liver with respect to the use <strong>of</strong> glycerol. N Engl J Med<br />
1968; 279: 965-970<br />
64 Arion WJ, Wallin BK, Lange AJ, Ballas LM. On the involvement<br />
<strong>of</strong> a glucose 6-phosphate transport system in the function <strong>of</strong><br />
microsomal glucose 6-phosphatase. Mol Cell Biochem 1975; 6:<br />
75-83<br />
65 Annabi B, Hiraiwa H, Mansfield BC, Lei KJ, Ubagai T,<br />
Polymeropoulos MH, Moses SW, Parvari R, Hershkovitz E,<br />
Mandel H, Fryman M, Chou JY. The gene for glycogen-storage<br />
disease type 1b maps to chromosome 11q23. Am J Hum Genet<br />
1998; 62: 400-405<br />
66 Ihara K, Kuromaru R, Hara T. Genomic structure <strong>of</strong> the<br />
www.wjgnet.com<br />
human glucose 6-phosphate translocase gene and novel<br />
mutations in the gene <strong>of</strong> a Japanese patient with glycogen<br />
storage disease type Ib. Hum Genet 1998; 103: 493-496<br />
67 Visser G, Rake JP, Fernandes J, Labrune P, Leonard JV, Moses<br />
S, Ullrich K, Smit GP. Neutropenia, neutrophil dysfunction,<br />
and inflammatory bowel disease in glycogen storage disease<br />
type Ib: results <strong>of</strong> the European Study on Glycogen Storage<br />
Disease type I. J Pediatr 2000; 137: <strong>18</strong>7-191<br />
68 Ihara K, Nomura A, Hikino S, Takada H, Hara T. Quantitative<br />
analysis <strong>of</strong> glucose-6-phosphate translocase gene expression in<br />
various human tissues and haematopoietic progenitor cells. J<br />
Inherit Metab Dis 2000; 23: 583-592<br />
69 Ueno N, Tomita M, Ariga T, Ohkawa M, Nagano S, Takahashi<br />
Y, Arashima S, Matsumoto S. Impaired monocyte function in<br />
glycogen storage disease type Ib. Eur J Pediatr 1986; 145: 312-314<br />
70 Leuzzi R, Banhegyi G, Kardon T, Marcolongo P, Capecchi PL,<br />
Burger HJ, Benedetti A, Fulceri R. Inhibition <strong>of</strong> microsomal<br />
glucose-6-phosphate transport in human neutrophils results in<br />
apoptosis: a potential explanation for neutrophil dysfunction<br />
in glycogen storage disease type 1b. Blood 2003; 101: 2381-2387<br />
71 Kure S, Hou DC, Suzuki Y, Yamagishi A, Hiratsuka M,<br />
Fukuda T, Sugie H, Kondo N, Matsubara Y, Narisawa K.<br />
Glycogen storage disease type Ib without neutropenia. J<br />
Pediatr 2000; 137: 253-256<br />
72 Roe TF, Thomas DW, Gilsanz V, Isaacs H Jr, Atkinson JB.<br />
Inflammatory bowel disease in glycogen storage disease type<br />
Ib. J Pediatr 1986; 109: 55-59<br />
73 Saltik-Temizel IN, Kocak N, Ozen H, Yuce A, Gurakan F,<br />
Demir H. Inflammatory bowel disease-like colitis in a young<br />
Turkish child with glycogen storage disease type 1b and<br />
elevated platelet count. Turk J Pediatr 2005; 47: <strong>18</strong>0-<strong>18</strong>2<br />
74 Melis D, Fulceri R, Parenti G, Marcolongo P, Gatti R, Parini<br />
R, Riva E, Della Casa R, Zammarchi E, Andria G, Benedetti A.<br />
Genotype/phenotype correlation in glycogen storage disease<br />
type 1b: a multicentre study and review <strong>of</strong> the literature. Eur J<br />
Pediatr 2005; 164: 501-508<br />
75 Martin AP, Bartels M, Schreiber S, Buehrdel P, Hauss J,<br />
Fangmann J. Successful staged kidney and liver transplantation<br />
for glycogen storage disease type Ib: A case report. Transplant<br />
Proc 2006; 38: 3615-3619<br />
76 Melis D, Pivonello R, Parenti G, Della Casa R, Salerno M,<br />
Lombardi G, Sebastio G, Colao A, Andria G. Increased<br />
prevalence <strong>of</strong> thyroid autoimmunity and hypothyroidism in<br />
patients with glycogen storage disease type I. J Pediatr 2007;<br />
150: 300-305, 305.e1<br />
77 Narisawa K, Otomo H, Igarashi Y, Arai N, Otake M, Tada<br />
K, Kuzuya T. Glycogen storage disease type 1b: microsomal<br />
glucose-6-phosphatase system in two patients with different<br />
clinical findings. Pediatr Res 1983; 17: 545-549<br />
78 Kovacevic A, Ehrlich R, Mayatepek E, Wendel U, Schwahn B.<br />
Glycogen storage disease type Ib without hypoglycemia. Mol<br />
Genet Metab 2007; 90: 349-350<br />
79 Greene HL, Slonim AE, O'Neill JA Jr, Burr IM. Continuous<br />
nocturnal intragastric feeding for management <strong>of</strong> type 1<br />
glycogen-storage disease. N Engl J Med 1976; 294: 423-425<br />
80 Chen YT, Cornblath M, Sidbury JB. Cornstarch therapy in type<br />
I glycogen-storage disease. N Engl J Med 1984; 310: 171-175<br />
81 Schroten H, Roesler J, Breidenbach T, Wendel U, Elsner J,<br />
Schweitzer S, Zeidler C, Burdach S, Lohmann-Matthes ML,<br />
Wahn V. Granulocyte and granulocyte-macrophage colonystimulating<br />
factors for treatment <strong>of</strong> neutropenia in glycogen<br />
storage disease type Ib. J Pediatr 1991; 119: 748-754<br />
82 Roe TF, Coates TD, Thomas DW, Miller JH, Gilsanz V. Brief<br />
report: treatment <strong>of</strong> chronic inflammatory bowel disease in<br />
glycogen storage disease type Ib with colony-stimulating<br />
factors. N Engl J Med 1992; 326: 1666-1669<br />
83 Yiu WH, Pan CJ, Allamarvdasht M, Kim SY, Chou JY. Glucose-<br />
6-phosphate transporter gene therapy corrects metabolic and<br />
myeloid abnormalities in glycogen storage disease type Ib<br />
mice. Gene Ther 2007; 14: 219-226<br />
84 Fenske CD, Jeffery S, Weber JL, Houlston RS, Leonard JV,<br />
Lee PJ. Localisation <strong>of</strong> the gene for glycogen storage disease<br />
type 1c by homozygosity mapping to 11q. J Med Genet 1998;
Özen H. . Glycogen storage diseases 2551<br />
35: 269-272<br />
85 Veiga-da-Cunha M, Gerin I, Chen YT, Lee PJ, Leonard<br />
JV, Maire I, Wendel U, Vikkula M, Van Schaftingen E. The<br />
putative glucose 6-phosphate translocase gene is mutated in<br />
essentially all cases <strong>of</strong> glycogen storage disease type I non-a.<br />
Eur J Hum Genet 1999; 7: 717-723<br />
86 Galli L, Orrico A, Marcolongo P, Fulceri R, Burchell A, Melis D,<br />
Parini R, Gatti R, Lam C, Benedetti A, Sorrentino V. Mutations<br />
in the glucose-6-phosphate transporter (G6PT) gene in patients<br />
with glycogen storage diseases type 1b and 1c. FEBS Lett 1999;<br />
459: 255-258<br />
87 Melis D, Havelaar AC, Verbeek E, Smit GP, Benedetti A,<br />
Mancini GM, Verheijen F. NPT4, a new microsomal phosphate<br />
transporter: mutation analysis in glycogen storage disease<br />
type Ic. J Inherit Metab Dis 2004; 27: 725-733<br />
88 Shen JJ, Chen YT. Molecular characterization <strong>of</strong> glycogen<br />
storage disease type III. Curr Mol Med 2002; 2: 167-175<br />
89 Bao Y, Dawson TL Jr, Chen YT. Human glycogen debranching<br />
enzyme gene (AGL): complete structural organization and<br />
characterization <strong>of</strong> the 5' flanking region. Genomics 1996; 38:<br />
155-165<br />
90 Bao Y, Yang BZ, Dawson TL Jr, Chen YT. Isolation and<br />
nucleotide sequence <strong>of</strong> human liver glycogen debranching<br />
enzyme mRNA: identification <strong>of</strong> multiple tissue-specific<br />
is<strong>of</strong>orms. Gene 1997; 197: 389-398<br />
91 Parvari R, Moses S, Shen J, Hershkovitz E, Lerner A, Chen<br />
YT. A single-base deletion in the 3'-coding region <strong>of</strong> glycogendebranching<br />
enzyme is prevalent in glycogen storage disease<br />
type IIIA in a population <strong>of</strong> North African Jewish patients. Eur<br />
J Hum Genet 1997; 5: 266-270<br />
92 Santer R, Kinner M, Steuerwald U, Kjærgaard S, Skovby F,<br />
Simonsen H, Shaiu WL, Chen YT, Schneppenheim R, Schaub<br />
J. Molecular genetic basis and prevalence <strong>of</strong> glycogen storage<br />
disease type IIIA in the Faroe Islands. Eur J Hum Genet 2001; 9:<br />
388-391<br />
93 Shen J, Bao Y, Liu HM, Lee P, Leonard JV, Chen YT. Mutations<br />
in exon 3 <strong>of</strong> the glycogen debranching enzyme gene are<br />
associated with glycogen storage disease type III that is<br />
differentially expressed in liver and muscle. J Clin Invest 1996;<br />
98: 352-357<br />
94 Van Ho<strong>of</strong> F, Hers HG. The subgroups <strong>of</strong> type 3 glycogenosis.<br />
Eur J Biochem 1967; 2: 265-270<br />
95 Ding JH, de Barsy T, Brown BI, Coleman RA, Chen YT.<br />
Immunoblot analyses <strong>of</strong> glycogen debranching enzyme in<br />
different subtypes <strong>of</strong> glycogen storage disease type III. J<br />
Pediatr 1990; 116: 95-100<br />
96 Momoi T, Sano H, Yamanaka C, Sasaki H, Mikawa H.<br />
Glycogen storage disease type III with muscle involvement:<br />
reappraisal <strong>of</strong> phenotypic variability and prognosis. Am J Med<br />
Genet 1992; 42: 696-699<br />
97 Coleman RA, Winter HS, Wolf B, Chen YT. Glycogen<br />
debranching enzyme deficiency: long-term study <strong>of</strong> serum<br />
enzyme activities and clinical features. J Inherit Metab Dis 1992;<br />
15: 869-881<br />
98 Lucchiari S, Pagliarani S, Salani S, Filocamo M, Di Rocco M,<br />
Melis D, Rodolico C, Musumeci O, Toscano A, Bresolin N,<br />
Comi GP. Hepatic and neuromuscular forms <strong>of</strong> glycogenosis<br />
type III: nine mutations in AGL. Hum Mutat 2006; 27: 600-601<br />
99 Moses SW, Wanderman KL, Myroz A, Frydman M. Cardiac<br />
involvement in glycogen storage disease type III. Eur J Pediatr<br />
1989; 148: 764-766<br />
100 Cleary MA, Walter JH, Kerr BA, Wraith JE. Facial appearance<br />
in glycogen storage disease type III. Clin Dysmorphol 2002; 11:<br />
117-120<br />
101 Coleman RA, Winter HS, Wolf B, Gilchrist JM, Chen YT.<br />
Glycogen storage disease type III (glycogen debranching<br />
enzyme deficiency): correlation <strong>of</strong> biochemical defects with<br />
myopathy and cardiomyopathy. Ann Intern Med 1992; 116:<br />
896-900<br />
102 Lee P, Burch M, Leonard JV. Plasma creatine kinase and<br />
cardiomyopathy in glycogen storage disease type III. J Inherit<br />
Metab Dis 1995; <strong>18</strong>: 751-752<br />
103 Demo E, Frush D, Gottfried M, Koepke J, Boney A, Bali D,<br />
Chen YT, Kishnani PS. Glycogen storage disease type IIIhepatocellular<br />
carcinoma a long-term complication? J Hepatol<br />
2007; 46: 492-498<br />
104 ANDERSEN DH. Familial cirrhosis <strong>of</strong> the liver with storage<br />
<strong>of</strong> abnormal glycogen. Lab Invest 1956; 5: 11-20<br />
105 Brown BI, Brown DH. Lack <strong>of</strong> an alpha-1,4-glucan: alpha-1,4glucan<br />
6-glycosyl transferase in a case <strong>of</strong> type IV glycogenosis.<br />
Proc Natl Acad Sci USA 1966; 56: 725-729<br />
106 Moses SW, Parvari R. The variable presentations <strong>of</strong> glycogen<br />
storage disease type IV: a review <strong>of</strong> clinical, enzymatic and<br />
molecular studies. Curr Mol Med 2002; 2: 177-<strong>18</strong>8<br />
107 Thon VJ, Khalil M, Cannon JF. Isolation <strong>of</strong> human glycogen<br />
branching enzyme cDNAs by screening complementation in<br />
yeast. J Biol Chem 1993; 268: 7509-7513<br />
108 L'hermine-Coulomb A, Beuzen F, Bouvier R, Rolland MO,<br />
Froissart R, Menez F, Audibert F, Labrune P. Fetal type IV<br />
glycogen storage disease: clinical, enzymatic, and genetic data<br />
<strong>of</strong> a pure muscular form with variable and early antenatal<br />
manifestations in the same family. Am J Med Genet A 2005; 139:<br />
1<strong>18</strong>-122<br />
109 Greene HL, Brown BI, McClenathan DT, Agostini RM Jr,<br />
Taylor SR. A new variant <strong>of</strong> type IV glycogenosis: deficiency<br />
<strong>of</strong> branching enzyme activity without apparent progressive<br />
liver disease. Hepatology 1988; 8: 302-306<br />
110 Schroder JM, May R, Shin YS, Sigmund M, Nase-Huppmeier S.<br />
Juvenile hereditary polyglucosan body disease with complete<br />
branching enzyme deficiency (type IV glycogenosis). Acta<br />
Neuropathol (Berl) 1993; 85: 419-430<br />
111 Servidei S, Riepe RE, Langston C, Tani LY, Bricker JT, Crisp-<br />
Lindgren N, Travers H, Armstrong D, DiMauro S. Severe<br />
cardiopathy in branching enzyme deficiency. J Pediatr 1987;<br />
111: 51-56<br />
112 Bruno C, van Diggelen OP, Cassandrini D, Gimpelev M, Giuffre<br />
B, Donati MA, Introvini P, Alegria A, Assereto S, Morandi L,<br />
Mora M, Tonoli E, Mascelli S, Traverso M, Pasquini E, Bado M,<br />
Vilarinho L, van Noort G, Mosca F, DiMauro S, Zara F, Minetti<br />
C. Clinical and genetic heterogeneity <strong>of</strong> branching enzyme<br />
deficiency (glycogenosis type IV). Neurology 2004; 63: 1053-1058<br />
113 Alegria A, Martins E, Dias M, Cunha A, Cardoso ML, Maire<br />
I. Glycogen storage disease type IV presenting as hydrops<br />
fetalis. J Inherit Metab Dis 1999; 22: 330-332<br />
114 Zellweger H, Mueller S, Ionasescu V, Schochet SS, McCormick<br />
WF. Glycogenosis. IV. A new cause <strong>of</strong> infantile hypotonia. J<br />
Pediatr 1972; 80: 842-844<br />
115 McMaster KR, Powers JM, Hennigar GR Jr, Wohltmann<br />
HJ, Farr GH Jr. Nervous system involvement in type IV<br />
glycogenosis. Arch Pathol Lab Med 1979; 103: 105-111<br />
116 Giuffre B, Parinii R, Rizzuti T, Morandi L, van Diggelen OP,<br />
Bruno C, Giuffre M, Corsello G, Mosca F. Severe neonatal<br />
onset <strong>of</strong> glycogenosis type IV: clinical and laboratory findings<br />
leading to diagnosis in two siblings. J Inherit Metab Dis 2004;<br />
27: 609-619<br />
117 Reusche E, Aksu F, Goebel HH, Shin YS, Yokota T, Reichmann<br />
H. A mild juvenile variant <strong>of</strong> type IV glycogenosis. Brain Dev<br />
1992; 14: 36-43<br />
1<strong>18</strong> Ferguson IT, Mahon M, Cumming WJ. An adult case<br />
<strong>of</strong> Andersen's disease--Type IV glycogenosis. A clinical,<br />
histochemical, ultrastructural and biochemical study. J Neurol<br />
Sci 1983; 60: 337-351<br />
119 Shin YS, Steiguber H, Klemm P, Endres W, Schwab O, Wolff<br />
G. Branching enzyme in erythrocytes. Detection <strong>of</strong> type IV<br />
glycogenosis homozygotes and heterozygotes. J Inherit Metab<br />
Dis 1988; 11 Suppl 2: 252-254<br />
120 Lossos A, Barash V, S<strong>of</strong>fer D, Argov Z, Gomori M, Ben-Nariah<br />
Z, Abramsky O, Steiner I. Hereditary branching enzyme<br />
dysfunction in adult polyglucosan body disease: a possible<br />
metabolic cause in two patients. Ann Neurol 1991; 30: 655-662<br />
121 Selby R, Starzl TE, Yunis E, Brown BI, Kendall RS, Tzakis A.<br />
Liver transplantation for type IV glycogen storage disease.<br />
New Eng J Med 1991; 324: 39-42<br />
122 Starzl TE, Demetris AJ, Trucco M, Ricordi C, Ildstad S,<br />
Terasaki PI, Murase N, Kendall RS, Kocova M, Rudert WA.<br />
Chimerism after liver transplantation for type IV glycogen<br />
www.wjgnet.com
2552 ISS� 1007-9327 C� 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 �umber <strong>18</strong><br />
storage disease and type 1 Gaucher's disease. N Engl J Med<br />
1993; 328: 745-749<br />
123 Newgard CB, Fletterick RJ, Anderson LA, Lebo RV. The<br />
polymorphic locus for glycogen storage disease VI (liver<br />
glycogen phosphorylase) maps to chromosome 14. Am J Hum<br />
Genet 1987; 40: 351-364<br />
124 Hers HG. Enzymatic studies <strong>of</strong> hepatic fragments; application<br />
to the classification <strong>of</strong> glycogenoses. Rev Int Hepatol 1959; 9:<br />
35-55<br />
125 Tang NL, Hui J, Young E, Worthington V, To KF, Cheung<br />
KL, Li CK, Fok TF. A novel mutation (G233D) in the glycogen<br />
phosphorylase gene in a patient with hepatic glycogen storage<br />
disease and residual enzyme activity. Mol Genet Metab 2003;<br />
79: 142-145<br />
126 Burwinkel B, Bakker HD, Herschkovitz E, Moses SW, Shin YS,<br />
Kilimann MW. Mutations in the liver glycogen phosphorylase<br />
gene (PYGL) underlying glycogenosis type VI. Am J Hum<br />
Genet 1998; 62: 785-791<br />
127 Davidson JJ, Ozcelik T, Hamacher C, Willems PJ, Francke<br />
U, Kilimann MW. cDNA cloning <strong>of</strong> a liver is<strong>of</strong>orm <strong>of</strong> the<br />
phosphorylase kinase alpha subunit and mapping <strong>of</strong> the<br />
gene to Xp22.2-p22.1, the region <strong>of</strong> human X-linked liver<br />
glycogenosis. Proc Natl Acad Sci USA 1992; 89: 2096-2100<br />
128 Hendrickx J, Willems PJ. Genetic deficiencies <strong>of</strong> the glycogen<br />
phosphorylase system. Hum Genet 1996; 97: 551-556<br />
129 Van den Berg IE, Berger R. Phosphorylase b kinase deficiency<br />
in man: a review. J Inherit Metab Dis 1990; 13: 442-451<br />
130 Hidaka F, Sawada H, Matsuyama M, Nunoi H. A novel<br />
mutation <strong>of</strong> the PHKA2 gene in a patient with X-linked liver<br />
glycogenosis type 1. Pediatr Int 2005; 47: 687-690<br />
131 Schimke RN, Zakheim RM, Corder RC, Hug G. Glycogen<br />
storage disease type IX: benign glycogenosis <strong>of</strong> liver and<br />
hepatic phosphorylase kinase deficiency. J Pediatr 1973; 83:<br />
1031-1034<br />
132 Willems PJ, Gerver WJ, Berger R, Fernandes J. The natural<br />
history <strong>of</strong> liver glycogenosis due to phosphorylase kinase<br />
deficiency: a longitudinal study <strong>of</strong> 41 patients. Eur J Pediatr<br />
1990; 149: 268-271<br />
133 Schippers HM, Smit GP, Rake JP, Visser G. Characteristic<br />
growth pattern in male X-linked phosphorylase-b kinase<br />
deficiency (GSD IX). J Inherit Metab Dis 2003; 26: 43-47<br />
134 Burwinkel B, Amat L, Gray RG, Matsuo N, Muroya K,<br />
Narisawa K, Sokol RJ, Vilaseca MA, Kilimann MW. Variability<br />
<strong>of</strong> biochemical and clinical phenotype in X-linked liver<br />
glycogenosis with mutations in the phosphorylase kinase<br />
PHKA2 gene. Hum Genet 1998; 102: 423-429<br />
135 Hendrickx J, Coucke P, Hors-Cayla MC, Smit GP, Shin<br />
YS, Deutsch J, Smeitink J, Berger R, Lee P, Fernandes J.<br />
Localization <strong>of</strong> a new type <strong>of</strong> X-linked liver glycogenosis to the<br />
chromosomal region Xp22 containing the liver alpha-subunit <strong>of</strong><br />
phosphorylase kinase (PHKA2). Genomics 1994; 21: 620-625<br />
136 Burwinkel B, Maichele AJ, Aagenaes O, Bakker HD, Lerner A,<br />
Shin YS, Strachan JA, Kilimann MW. Autosomal glycogenosis<br />
<strong>of</strong> liver and muscle due to phosphorylase kinase deficiency is<br />
caused by mutations in the phosphorylase kinase beta subunit<br />
(PHKB). Hum Mol Genet 1997; 6: 1109-1115<br />
137 Bashan N, Iancu TC, Lerner A, Fraser D, Potashnik R, Moses<br />
SW. Glycogenosis due to liver and muscle phosphorylase<br />
kinase deficiency. Pediatr Res 1981; 15: 299-303<br />
138 Maichele AJ, Burwinkel B, Maire I, Sovik O, Kilimann MW.<br />
Mutations in the testis/liver is<strong>of</strong>orm <strong>of</strong> the phosphorylase<br />
kinase gamma subunit (PHKG2) cause autosomal liver<br />
glycogenosis in the gsd rat and in humans. Nat Genet 1996; 14:<br />
337-340<br />
139 Burwinkel B, Shiomi S, Al Zaben A, Kilimann MW. Liver<br />
glycogenosis due to phosphorylase kinase deficiency: PHKG2<br />
gene structure and mutations associated with cirrhosis. Hum<br />
Mol Genet 1998; 7: 149-154<br />
140 Manz F, Bickel H, Brodehl J, Feist D, Gellissen K, Gescholl-<br />
Bauer B, Gilli G, Harms E, Helwig H, Nutzenadel W. Fanconi-<br />
Bickel syndrome. Pediatr Nephrol 1987; 1: 509-5<strong>18</strong><br />
141 Fanconi G, Bickel H. Not Available Helv Paediatr Acta 1949; 4:<br />
359-396<br />
www.wjgnet.com<br />
142 Saltik-Temizel IN, Coskun T, Yuce A, Kocak N. Fanconi-<br />
Bickel syndrome in three Turkish patients with different<br />
homozygous mutations. Turk J Pediatr 2005; 47: 167-169<br />
143 Fukumoto H, Seino S, Imura H, Seino Y, Eddy RL, Fukushima<br />
Y, Byers MG, Shows TB, Bell GI. Sequence, tissue distribution,<br />
and chromosomal localization <strong>of</strong> mRNA encoding a human<br />
glucose transporter-like protein. Proc Natl Acad Sci USA 1988;<br />
85: 5434-5438<br />
144 Santer R, Schneppenheim R, Dombrowski A, Gotze H,<br />
Steinmann B, Schaub J. Mutations in GLUT2, the gene for the<br />
liver-type glucose transporter, in patients with Fanconi-Bickel<br />
syndrome. Nat Genet 1997; 17: 324-326<br />
145 Aperia A, Bergqvist G, Linne T, Zetterstrom R. Familial<br />
Fanconi syndrome with malabsorption and galactose<br />
intolerance, normal kinase and transferase activity. A report<br />
on two siblings. Acta Paediatr Scand 1981; 70: 527-533<br />
146 Muller D, Santer R, Krawinkel M, Christiansen B, Schaub J.<br />
Fanconi-Bickel syndrome presenting in neonatal screening for<br />
galactosaemia. J Inherit Metab Dis 1997; 20: 607-608<br />
147 Lee PJ, Van't H<strong>of</strong>f WG, Leonard JV. Catch-up growth in<br />
Fanconi-Bickel syndrome with uncooked cornstarch. J Inherit<br />
Metab Dis 1995; <strong>18</strong>: 153-156<br />
148 Odievre M. Hepato-renal glycogenosis with complex<br />
tubulopathy. 2. Cases <strong>of</strong> a new entity. Rev Int Hepatol 1966; 16:<br />
1-70<br />
149 Haines JL, Ozelius LJ, McFarlane H, Menon A, Tzall S,<br />
Martiniuk F, Hirschhorn R, Gusella JF. A genetic linkage map<br />
<strong>of</strong> chromosome 17. Genomics 1990; 8: 1-6<br />
150 Ausems MG, Verbiest J, Hermans MP, Kroos MA, Beemer<br />
FA, Wokke JH, Sandkuijl LA, Reuser AJ, van der Ploeg<br />
AT. Frequency <strong>of</strong> glycogen storage disease type II in<br />
The Netherlands: implications for diagnosis and genetic<br />
counselling. Eur J Hum Genet 1999; 7: 713-716<br />
151 Matsuishi T, Yoshino M, Terasawa K, Nonaka I. Childhood<br />
acid maltase deficiency. A clinical, biochemical, and<br />
morphologic study <strong>of</strong> three patients. Arch Neurol 1984; 41:<br />
47-52<br />
152 Reuser AJ, Kroos M, Willemsen R, Swallow D, Tager<br />
JM, Galjaard H. Clinical diversity in glycogenosis type II.<br />
Biosynthesis and in situ localization <strong>of</strong> acid alpha-glucosidase<br />
in mutant fibroblasts. J Clin Invest 1987; 79: 1689-1699<br />
153 Slonim AE, Bulone L, Ritz S, Goldberg T, Chen A, Martiniuk<br />
F. Identification <strong>of</strong> two subtypes <strong>of</strong> infantile acid maltase<br />
deficiency. J Pediatr 2000; 137: 283-285<br />
154 Beratis NG, LaBadie GU, Hirschhorn K. Characterization<br />
<strong>of</strong> the molecular defect in infantile and adult acid alphaglucosidase<br />
deficiency fibroblasts. J Clin Invest 1978; 62:<br />
1264-1274<br />
155 Francesconi M, Auff E. Cardiac arrhythmias and the adult<br />
form <strong>of</strong> type II glycogenosis. N Engl J Med 1982; 306: 937-938<br />
156 Makos MM, McComb RD, Hart MN, Bennett DR. Alphaglucosidase<br />
deficiency and basilar artery aneurysm: report <strong>of</strong><br />
a sibship. Ann Neurol 1987; 22: 629-633<br />
157 Amartino H, Painceira D, Pomponio RJ, Niizawa G, Sabio Paz<br />
V, Blanco M, Chamoles N. Two clinical forms <strong>of</strong> glycogenstorage<br />
disease type II in two generations <strong>of</strong> the same family.<br />
Clin Genet 2006; 69: <strong>18</strong>7-<strong>18</strong>8<br />
158 Ausems MG, Lochman P, van Diggelen OP, Ploos van Amstel<br />
HK, Reuser AJ, Wokke JH. A diagnostic protocol for adultonset<br />
glycogen storage disease type II. Neurology 1999; 52:<br />
851-853<br />
159 Slonim AE, Coleman RA, McElligot MA, Najjar J, Hirschhorn<br />
K, Labadie GU, Mrak R, Evans OB, Shipp E, Presson R.<br />
Improvement <strong>of</strong> muscle function in acid maltase deficiency by<br />
high-protein therapy. Neurology 1983; 33: 34-38<br />
160 Isaacs H, Savage N, Badenhorst M, Whistler T. Acid maltase<br />
deficiency: a case study and review <strong>of</strong> the pathophysiological<br />
changes and proposed therapeutic measures. J Neurol<br />
Neurosurg Psychiatry 1986; 49: 1011-10<strong>18</strong><br />
161 Amalfitano A, Bengur AR, Morse RP, Majure JM, Case LE,<br />
Veerling DL, Mackey J, Kishnani P, Smith W, McVie-Wylie<br />
A, Sullivan JA, Hoganson GE, Phillips JA 3rd, Schaefer GB,<br />
Charrow J, Ware RE, Bossen EH, Chen YT. Recombinant
Özen H. . Glycogen storage diseases 2553<br />
human acid alpha-glucosidase enzyme therapy for infantile<br />
glycogen storage disease type II: results <strong>of</strong> a phase I/II clinical<br />
trial. Genet Med 2001; 3: 132-138<br />
162 Lebo RV, Anderson LA, DiMauro S, Lynch E, Hwang P,<br />
Fletterick R. Rare McArdle disease locus polymorphic site on<br />
11q13 contains CpG sequence. Hum Genet 1990; 86: 17-24<br />
163 Grunfeld JP, Ganeval D, Chanard J, Fardeau M, Dreyfus JC.<br />
Acute renal failure in McArdle's disease. Report <strong>of</strong> two cases.<br />
N Engl J Med 1972; 286: 1237-1241<br />
164 Howard TD, Akots G, Bowden DW. Physical and genetic<br />
mapping <strong>of</strong> the muscle phosph<strong>of</strong>ructokinase gene (PFKM):<br />
reassignment to human chromosome 12q. Genomics 1996; 34:<br />
122-127<br />
165 Tarui S, Okuno G, Ikura Y, Tanaka T, Suda M, Nishikawa M.<br />
Phosph<strong>of</strong>ructokinase deficiency in skeletal muscle. A new type<br />
<strong>of</strong> glycogenosis. Biochem Biophys Res Commun 1965; 19: 517-523<br />
S- Editor Zhu LH L- Editor Zhu LH E- Editor Chen GJ<br />
www.wjgnet.com
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2554-2567<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
TOPIC HIGHLIGHT<br />
Giuseppe Montalto, Series Editor<br />
Future prospectives for the management <strong>of</strong> chronic hepatitis B<br />
WF Leemans, HLA Janssen, RA de Man<br />
WF Leemans, HLA Janssen, RA de Man, Department <strong>of</strong><br />
<strong>Gastroenterology</strong> & Hepatology, Erasmus MC, University<br />
Medical Center, Rotterdam, The Netherlands<br />
Correspondence to: RA de Man, MD, PhD, Department <strong>of</strong><br />
<strong>Gastroenterology</strong> and Hepatology, Room H 437, Erasmus MC,<br />
University Medical Center Rotterdam’s-Gravendijkwal 230, 3015<br />
CE Rotterdam, The Netherlands. r.deman@erasmusmc.nl<br />
Telephone: +31-104-635942 Fax: +31-104-365916<br />
Received: 2006-12-15 Accepted: 2007-03-08<br />
Abstract<br />
Chronic hepatitis B virus infection affects about<br />
400 million people around the globe and causes<br />
approximately a million deaths a year. Since the discovery<br />
<strong>of</strong> interferon-α as a therapeutic option the treatment<br />
<strong>of</strong> hepatitis B has evolved fast and management has<br />
become increasingly complicated. The amount <strong>of</strong> viral<br />
replication reflected in the viral load (HBV-DNA) plays<br />
an important role in the development <strong>of</strong> cirrhosis<br />
and hepatocellular carcinoma. The current treatment<br />
modalities for chronic hepatitis B are immunomodulatory<br />
(interferons) and antiviral suppressants (nucleoside and<br />
nucleotide analogues) all with their own advantages<br />
and limitations. An overview <strong>of</strong> the treatment efficacy<br />
for both immunomodulatory as antiviral compounds is<br />
provided in order to provide the clinician insight into the<br />
factors influencing treatment outcome. With nucleoside<br />
or nucleotide analogues suppression <strong>of</strong> viral replication<br />
by 5-7 log10 is feasible, but not all patients respond to<br />
therapy. Known factors influencing treatment outcome<br />
are viral load, ALT levels and compliance. Many other<br />
factors which might influence treatment are scarcely<br />
investigated. Identifying the factors associated with<br />
response might result in stopping rules, so treatment<br />
could be adapted in an early stage to provide adequate<br />
treatment and avoid the development <strong>of</strong> resistance. The<br />
efficacy <strong>of</strong> compounds for the treatment <strong>of</strong> mutant virus<br />
and the cross-resistance is largely unknown. However,<br />
genotypic and phenotypic testing as well as small clinical<br />
trials provided some data on efficacy in this population.<br />
Discontinuation <strong>of</strong> nucleoside or nucleotide analogues<br />
frequently results in viral relapse; however, some patients<br />
have a sustained response. Data on the risk factors<br />
for relapse are necessary in order to determine when<br />
treatment can be discontinued safely. In conclusion:<br />
chronic hepatitis B has become a treatable disease;<br />
however, much research is needed to tailor therapy to<br />
an individual patient, to predict the sustainability <strong>of</strong><br />
response and determine the best treatment for those<br />
www.wjgnet.com<br />
failing treatment.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Hepatitis B virus; Cirrhosis; Treatment;<br />
Interferon; Nucleoside analogues; Nucleotide analogues;<br />
Lamivudine; Adefovir; Entecavir; Telbivudine; Ten<strong>of</strong>ovir;<br />
Resistance; Genotype<br />
Leemans WF, Janssen HLA, de Man RA. Future prospectives<br />
for the management <strong>of</strong> chronic hepatitis B. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2554-2567<br />
http://www.wjgnet.com/1007-9327/13/2554.asp<br />
INTRODUCTION<br />
Treatment <strong>of</strong> chronic hepatitis B remains an important<br />
clinical objective. Estimates are that 2 billion people have<br />
been infected worldwide and chronic hepatitis B currently<br />
affects about 400 million people, particularly in developing<br />
countries [1] . Chronic hepatitis B is responsible 500 000<br />
to 1.2 million deaths annually from liver cirrhosis and<br />
hepatocellular carcinoma (HCC) [2] . It is one <strong>of</strong> the most<br />
common infectious diseases and among the world’s leading<br />
causes <strong>of</strong> death. There are two strategies to decrease these<br />
numbers, prevention <strong>of</strong> new infections and treatment<br />
<strong>of</strong> those already chronically infected. Treatment options<br />
consist <strong>of</strong> immunomodulatory and viral suppressant<br />
drugs. In this review the current standard <strong>of</strong> care and the<br />
future developments in the field <strong>of</strong> chronic hepatitis B are<br />
discussed.<br />
WHAT IS THE OPTIONAL TREATMENT<br />
Naïve patients<br />
The ideal treatment for hepatitis B is an effective cheap<br />
treatment, resulting in HBsAg loss and formation <strong>of</strong><br />
anti-HBs, with finite treatment duration and little side<br />
effects. Currently none <strong>of</strong> the HBV treatments fulfill<br />
these conditions. With interferon based therapy HBsAg<br />
loss occurs in 3%-10% <strong>of</strong> the patients within one year <strong>of</strong><br />
start <strong>of</strong> therapy and increases in sustained responders to<br />
11%-32% [3-9] . HBsAg loss is rare (< 2% after one year <strong>of</strong><br />
treatment) in patients treated with nucleos(t)ide analogues,<br />
which is about the rate observed in the natural history<br />
<strong>of</strong> the disease [10-16] . However, in a small cohort treated<br />
with ten<strong>of</strong>ovir, HBsAg loss was observed in 14% <strong>of</strong> 35
Leemans WF et al . Management <strong>of</strong> chronic HBV 2555<br />
Table 1 Baseline factors influencing likelihood <strong>of</strong> response to antiviral therapy<br />
Treatment Increased likelihood <strong>of</strong> response Decreased likelihood <strong>of</strong> response<br />
(PEG) interferon Baseline ALT > 2 ULN [28,145,146]<br />
Baseline ALAT < 2 ULN [28,145,146]<br />
Baseline HBV DNA < 10 9 c/mL [4,28]<br />
Baseline HBV DNA > 10 9 c/mL [4,28]<br />
Genotype A or B<br />
Longer treatment duration<br />
Genotype C or D<br />
[33-35,147]<br />
Nucleoside/nucleotide<br />
analogues<br />
ULN: Upper limit <strong>of</strong> normal; c/p = copies/mL.<br />
[148, 149]<br />
Baseline serum aminotransferases > 2 ULN<br />
Baseline HBV DNA < 10 9 c/mL [148]<br />
patients [17] . More large size trials have to be conducted<br />
to investigate the rate <strong>of</strong> HBsAg loss for the newer<br />
nucleos(t)ide analogues or their combinations. Treatment<br />
with Interferon-α or PEG-interferon-α treatment is<br />
<strong>of</strong> finite duration and response is <strong>of</strong>ten durable <strong>of</strong>ftreatment.<br />
However, this treatment has side effects and<br />
only a minority responds. Nucleosides/nucleotides are<br />
well tolerated and most patients respond to therapy but<br />
treatment is hampered by the selection <strong>of</strong> drug resistant<br />
mutants leading to loss <strong>of</strong> efficacy and frequent relapse<br />
after discontinuation. As none <strong>of</strong> the current registered<br />
therapies for chronic HBV is ideal, none <strong>of</strong> the drugs<br />
is regarded as the standard first-line therapy for HBV.<br />
Strategies have particularly aimed at selecting host and<br />
virus characteristics either before or during therapy to<br />
increase treatment efficacy and also withdraw ineffective<br />
treatments. The argument about the poor tolerability <strong>of</strong><br />
interferon has been weakened by the introduction <strong>of</strong><br />
PEG-interferon-α, which only has to be administered<br />
once a week. Furthermore it is believed PEG-interferon-α<br />
is more potent than the conventional interferons; however<br />
good comparative studies have not been performed [<strong>18</strong>] .<br />
Based on treatment outcomes, the preferable treatment<br />
shifts to interferon based therapy or nucleoside/nucleotide<br />
analogue therapy for different patient groups. In Table 1<br />
the known predictors for response are given for both<br />
interferon-α based therapies or nucleos(t)ide analogues.<br />
Recent studies found a strong correlation between<br />
HBV DNA level and the development <strong>of</strong> liver cirrhosis<br />
and HCC. However, as none <strong>of</strong> the studies concerning<br />
natural history separately analysed the outcome in patients<br />
with prolonged normal aminotransferases the exact<br />
influence <strong>of</strong> the viral load is not known [19-21] . Interferon<br />
based therapies are generally ineffective in patients with<br />
low pre-treatment serum aminotransferase levels, and for<br />
these patients nucleoside/nucleotide treatment would be<br />
indicated. Low pre-treatment serum aminotransferases<br />
and high HBV DNA levels also decrease the likelihood <strong>of</strong><br />
response for these agents; however, this confers to HBeAg<br />
loss/seroconversion. In theory nucleoside/nucleotide<br />
analogues are effective in lowering the viral load and<br />
thereby decreasing the risk for development <strong>of</strong> cirrhosis<br />
and HCC [22] . However, the benefit <strong>of</strong> this approach on<br />
survival is not supported by clinical trials.<br />
For therapy <strong>of</strong> treatment naïve patients with elevated<br />
ALT levels, consensus guidelines have no preference for<br />
interferon or nucleoside/nucleotide therapy. Treatment<br />
outcomes for different therapies are provided in Table 2.<br />
Baseline serum aminotransferases < 2 [148,149]<br />
Baseline HBV DNA > 10 9 c/mL [148]<br />
Genotype proved to be an important predictor for the<br />
response to interferon-α or PEG-interferon-α therapy,<br />
especially in HBeAg positive patients. Genotype A and<br />
B show superior end <strong>of</strong> treatment responses as well as<br />
<strong>of</strong>f treatment responses compared to genotypes C and<br />
D [3,4,<strong>18</strong>,23-25] . HBeAg loss occurred in 34%-36% <strong>of</strong> patients.<br />
In addition HBsAg seroconversion was observed in<br />
13%-22% <strong>of</strong> patients with genotype A [<strong>18</strong>,26,27] . Therefore, a<br />
48 wk course <strong>of</strong> PEG-interferon-α should be considered<br />
as first-line therapy for HBeAg positive patients with<br />
genotype A or B.<br />
For HBeAg negative patients the distinctions are less<br />
clear. Genotype D responds less to PEG-interferon-α<br />
compared to genotypes A, B or C. Sustained ALT<br />
normalisation and a viral load < 20 000 copies/mL was<br />
observed in 27%, 44%, 52% and 16%, for genotype A,<br />
B, C and D, respectively. Sustained response occurred<br />
significantly more frequently in genotypes B and C<br />
compared to genotype D. The difference in sustained<br />
response between genotype A and D was not significant,<br />
probably due to the small number <strong>of</strong> genotype A infected<br />
patients [28] . However, only patients with genotype A, treated<br />
with PEG-interferon-α for 48 wk, had a considerable<br />
chance (<strong>18</strong>%) to develop HBsAg seroconversion [27] . The<br />
long-term follow-up is not known for PEG-interferon-α.<br />
Two years <strong>of</strong> follow-up showed a decrease in response<br />
(HBV DNA < 2.0 × 10 4 copies/mL) from 43% after 24<br />
wk <strong>of</strong> follow-up to 29% [29] . However, long-term follow-up<br />
studies with conventional interferon showed high relapse<br />
rates [2,5,30] . Nucleos(t)ide analogues are effective across all<br />
genotypes in both HBeAg positive and HBeAg negative<br />
patients and have proven to be a good treatment option<br />
for chronic active hepatitis B [31,32] .<br />
Retreatment <strong>of</strong> non-responders<br />
Treatment <strong>of</strong> non-responders to previous treatment is<br />
little studied and most studies are <strong>of</strong> small size. Studies<br />
show that retreatment with conventional interferon can<br />
induce HBV DNA loss and HBeAg seroconversion;<br />
however the overall results are not conclusive (Table 3).<br />
Most <strong>of</strong> the results are difficult to interpret as the initial<br />
schedule <strong>of</strong> interferon therapy differs as well as the time<br />
to retreatment. The retreatment schedules <strong>of</strong>ten differ<br />
from the initial schedule, and treatment duration is <strong>of</strong>ten<br />
prolonged influencing treatment outcome positively [33-35] .<br />
The real benefit <strong>of</strong> interferon retreatment, especially with<br />
pegylated interferon is unclear. Nucleos(t)ide analogues<br />
appear to be effective in interferon failures, although<br />
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2556 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Table 2 Treatment outcomes after 1 year <strong>of</strong> treatment for different antiviral drugs for the management <strong>of</strong> chronic hepatitis B<br />
Author; <strong>Journal</strong>; Year HBeAg<br />
loss<br />
(%)<br />
HBeAg<br />
seroconversion<br />
(%)<br />
HBsAg<br />
loss<br />
(%)<br />
Decline<br />
viral load (log10<br />
copies/mL)<br />
HBV DNA<br />
negativity<br />
(%)<br />
ALT<br />
normalisation<br />
(%)<br />
Histological<br />
improvement<br />
(%)<br />
HBeAg pos<br />
PEG-IFN-α 2a Cooksley; J. Viral Hepatitis; 2003 [<strong>18</strong>]13<br />
35 33 39 9<br />
35<br />
PEG-IFN-α 2a Lau: NEJM; 2005 [4]<br />
34 32 3 12<br />
2.4 14 4<br />
41 49<br />
PEG-IFN-α 2b Janssen; Lancet; 2005 [3]<br />
36 29 7 2.3 7 4<br />
32 53 10<br />
Lamivudine Chang; NEJM; 2006 [13]<br />
20 <strong>18</strong> 1 5.4 36 2<br />
60 62 13<br />
Lamivudine Alexander; BMC Gastroenter; 2005 [150] 42 28 56 10<br />
Lamivudine Chan; Ann Intern Med; 2005 [151]<br />
28 28 0 2.74 10 1<br />
78 59 11<br />
40<br />
Lamivudine Yao; Hepatobil Pancr Dis Int; 2004 [152] 10 8 36 72 12<br />
Lamivudine Jonas; NEJM; 2002 [153]<br />
26 2 61 6<br />
55 19<br />
Lamivudine Mazur; Med Sci Monit; 2002 [154]<br />
49 44 5 37 8<br />
56<br />
Lamivudine Barbaro; J Hepatol: 2001 [155]<br />
19 0 23 27 10<br />
16<br />
Lamivudine Dienstag; NEJM 1999 [47]<br />
32 17 2 44 7<br />
41 52 10<br />
32<br />
Lamivudine Gane; J Hepatol; 2006 [63]<br />
23 21 5.5 40 2<br />
75 56 8<br />
Adefovir Marcelin; NEJM; 2003 [16]<br />
24 12 3.6 21 4<br />
48 53 0<br />
Adefovir Lee; Hepatology; 2006 [102]<br />
14 4.0 29 5<br />
79 0<br />
Adefovir 15<br />
Zheng; Hepatology; 2006 [124]<br />
13 8 0 4.5 28 2<br />
79 0<br />
Adefovir Bzowej; Hepatology; 2006 [65]<br />
20 <strong>18</strong> 5.7 39 2<br />
81 2<br />
Entecavir Chang; NEJM; 2006 [13]<br />
22 21 2 6.9 67 2<br />
68 72 0<br />
Telbivudine Gane; J Hepatol; 2006 [63]<br />
26 22 6.5 60 2<br />
77 65 3<br />
Telbivudine Bzowej; Hepatology; 2006 [65]<br />
31 27 6.6 58 2<br />
HBeAg neg<br />
77 4<br />
PEG-IFN-α 2a Marcellin; NEJM; 2004 [5]<br />
4 2.3 19 4<br />
59 59<br />
Lamivudine Marcellin; NEJM; 2004 [5]<br />
0 4.2 73 4<br />
73 58 14<br />
41<br />
Lamivudine Lai; NEJM; 2006 [15]<br />
0 4.5 72 2<br />
71 61 6<br />
Lamivudine Lai; NEJM; 1999 16 0 72 56 10<br />
14<br />
Adefovir Hadzyannis; NEJM; 2003 [14]<br />
3.9 51 4<br />
72 64 0<br />
Entecavir Lai; NEJM; 2006 [15]<br />
0 5.0 90 2<br />
Mixed<br />
78 70 0<br />
Lamivudine Ooga; J <strong>Gastroenterology</strong>; 2004 [156]<br />
78 5<br />
78 16<br />
Lamivudine Suzuki; Intervirology; 2003 [108]<br />
42 28 0 88 6<br />
86<br />
Lamivudine Yao; J Hepatology; 2006 [64]<br />
<strong>18</strong> 4.3 43 2<br />
78<br />
Entecavir Yao; J Hepatology; 2006 [64]<br />
15 5.9 76 2<br />
90<br />
Resistance<br />
(%)<br />
Although conventional interferon-α is widely used for the treatment <strong>of</strong> HBV it is not listed as this treatment will be replaced by PEG-interferon-α in the near<br />
future. Efficacy measures for PEG-interferon presented are <strong>of</strong>f-treatment responses after 24 wk <strong>of</strong> follow-up. Studies are organised by HBeAg status and the<br />
mixed studies included both HBeAg positive as HBeAg negative patients. 1 LLD 200 copies/mL; 2 LLD 300 copies/mL; 3 LLD 366 copies/mL; 4 400 copies/mL; 5 5.0<br />
× 10 3 copies/mL; 6 7.0 × 10 5 copies/mL; 7 1.0 × 10 6 copies/mL; 8 1.4 × 10 6 copies/mL; 9 5.0 × 10 6 copies/mL; 10 only improvement <strong>of</strong> ≥ 2 points in necroinflammation<br />
according to Ishak, 11 only improvement <strong>of</strong> ≥ 2 points in necroinflammation according to Knodell, 12 HBsAg seroconversion, 13 treatment duration 24 wk, 14 After 24<br />
wk <strong>of</strong> follow-up, Lamivudine study performed in children, 15 Includes some lamivudine resistant patients.<br />
Table 3 Response to interferon-α or PEG-interferon-α after having failed a prior course <strong>of</strong> interferon or response to interferon-α or<br />
PEG-interferon-α after having failed a prior course <strong>of</strong> lamivudine<br />
Author; <strong>Journal</strong>; Year Treatment regimen Pretreatment<br />
HBeAg status (n )<br />
Janssen; J Hepatology; 1993 [157]<br />
Carreno; Hepatology; 1999 [158]<br />
Munoz; J Hepatology; 2002 [159]<br />
Munoz; J Hepatology; 2002 [159]<br />
Ballauff; Eur J Pediatr; [160]<br />
Teuber; Z Gastroenterol; 1995 [161]<br />
Flink; Hepatology; 2004 [162]<br />
Lau; J Hepatology; 2005 [163]<br />
Prev lamivudine<br />
Flink; Hepatology; 2004 [162]<br />
HBeAg loss HBeAg<br />
HBV DNA<br />
seroconversion (%) loss (%)<br />
IFN 1.5 MU daily for 4 wk followed<br />
by 3 MU daily for 8 wk and then 5<br />
MU daily for 4 wk<br />
Positive (<strong>18</strong>) 11 17<br />
IFN 9 MU thrice weekly for 24 wk Positive (27) 41 22 44 5<br />
IFN 6 MU 5 times weekly for 24 wk Positive (11) <strong>18</strong> <strong>18</strong> 1<br />
IFN 6 MU 5 times weekly for 24 wk Negative (<strong>18</strong>) 22 1<br />
IFN 5-9 MU/m 2 thrice weekly for<br />
16-24 wk<br />
Positive (15) 33 33 4<br />
Positive (27) 30 59<br />
PEG-IFN-α 2b 100 μg/wk for 32 wk<br />
followed by 50 μg/wk for 20 wk<br />
Positive (<strong>18</strong>) 28 0 2<br />
PEG-IFN-α 2a for 48 wk Positive (30) 43<br />
PEG-IFN-α 2b 100 μg/wk for 32 wk<br />
followed by 50 μg/wk for 20 wk<br />
Positive (8) 50 0 2<br />
Lau; J Hepatology; 2005 [163]<br />
PEG-IFN-α 2a <strong>18</strong>0 μg/wk for 48 wk Positive (31) 32<br />
Marcellin; J Hepatology; 2006 [164] PEG-IFN-α 2a 90-<strong>18</strong>0 μg/wk for<br />
median 48 wk<br />
Positive (71) 37 6<br />
32 6<br />
47 3,6<br />
Marcellin; J Hepatology; 2006 [164] PEG-IFN-α 2a 90-<strong>18</strong>0 μg/wk for<br />
median 48 wk<br />
Negative (36) 67 3,6<br />
ALT<br />
normalisation (%)<br />
1 LLD 200 copies/mL; 2 LLD 400 copies/mL; 3 LLD 1.0 × 10 4 copies/mL; 4 LLD 4.25 × 10 5 copies/mL; 5 LLD 4.81 × 10 5 copies/mL; 6 on-treatment responses.<br />
www.wjgnet.com<br />
22<br />
<strong>18</strong><br />
44<br />
22<br />
47<br />
51<br />
52
Leemans WF et al . Management <strong>of</strong> chronic HBV 2557<br />
efficacy may be different and data are limited [36] . A clinical<br />
trial using adefovir dipivoxil included 123 HBeAg positive<br />
and 48 HBeAg negative patients failing prior interferon<br />
therapy. HBeAg seroconversion rates were similar for<br />
interferon naïve and experienced patients [37] . The efficacy<br />
<strong>of</strong> the use <strong>of</strong> interferon for lamivudine failures is unclear<br />
(Tables 3 and 4). It appears interferon is effective in<br />
patients who received lamivudine, but did not develop<br />
resistance. Interferon-α therapy probably has a low efficacy<br />
in lamivudine resistant patients, but the numbers published<br />
are small [38,39] .<br />
Cirrhotic patients<br />
The life expectancy <strong>of</strong> patients with cirrhosis, if untreated,<br />
is greatly diminished with a 5-year survival <strong>of</strong> 84%<br />
for compensated and 14%-35% for decompensated<br />
cirrhosis [40-42] . Interferon has to be used with caution in<br />
cirrhotic patients and its use is limited to Child A cirrhosis.<br />
Interferon may be effective in compensated cirrhotics<br />
in which treatment outcomes do not differ from those<br />
without cirrhosis [6,33,35,43,44] . Adverse events, dose reductions<br />
and early discontinuation occur more frequently in<br />
cirrhotic patients [45,46] . Nucleos(t)ide analogues appear to<br />
be as effective in cirrhotics as in those without cirrhosis<br />
regardless <strong>of</strong> HBeAg status [47-49] . Lamivudine treatment<br />
in patients with advanced fibrosis or compensated<br />
cirrhosis reduced the progression <strong>of</strong> liver disease. Loss<br />
<strong>of</strong> efficacy due to resistance resulted in an increase <strong>of</strong><br />
disease progression [50] . Entecavir treatment resulted in<br />
undetectable HBV DNA loss (LLD 300 copies/mL) in<br />
> 90%, ALT normalisation in over 60% and histological<br />
improvement in > 70% <strong>of</strong> patients with compensated<br />
cirrhosis [51] .<br />
Decompensated cirrhotic patients should be treated<br />
with nucleoside analogues as interferon-α is contraindicated<br />
[52,53] . The timing <strong>of</strong> the initiation <strong>of</strong> therapy<br />
is essential. If the bilirubin level has risen above 3.5<br />
mg/dL the 3 mo survival is poor and probably cannot<br />
be influenced by nucleos(t)ide analogue therapy. Several<br />
studies have confirmed the efficacy <strong>of</strong> lamivudine<br />
therapy in patients with HBV related decompensated<br />
cirrhosis. Therapy resulted in a significant improvement in<br />
virological, biochemical and markers <strong>of</strong> disease status [54-58] .<br />
Treatment <strong>of</strong> lamivudine refractory patients, who<br />
waited for liver transplantation, with adefovir for 48 wk<br />
resulted in a 4.1 log10 copy decline in viral load. Liver<br />
functions improved significantly and the Child Pugh-<br />
Turcotte score (CPT) improved or remained stable in<br />
92% <strong>of</strong> the patients [59] . Adefovir therapy initiated in pretransplant<br />
patients resulted in undetectable serum HBV<br />
DNA in 76% and normal ALT in 84% <strong>of</strong> the patients<br />
after 96 wk <strong>of</strong> treatment. Markers <strong>of</strong> synthetic liver<br />
function improved in most patients, the Child-Pugh<br />
scores improved, or remained the same and survival was<br />
over 80% after two years [60] . Another study in lamivudine<br />
refractory patients with decompensated cirrhosis showed<br />
a HBV DNA response (≤ 10 5 copies/mL or ≥ 2 log<br />
decrease from baseline) in 92%, over half <strong>of</strong> the patients<br />
had ALT normalisation and there was improvement <strong>of</strong><br />
liver synthesis function and Child-Pugh scores after one<br />
year <strong>of</strong> treatment [61] . Although it is possible to inhibit<br />
viral replication and prevent clinical decompensation,<br />
the occurrence <strong>of</strong> HCC is not prevented. After 5 years<br />
<strong>of</strong> continuous lamivudine therapy or add-on therapy<br />
with adefovir in lamivudine resistant cases in HBeAg<br />
negative cirrhotic patients, 16% <strong>of</strong> patients had died, or<br />
had a liver transplantation. However, 24% was diagnosed<br />
with HCC [62] . The moment <strong>of</strong> initiation <strong>of</strong> nucleos(t)ide<br />
analogues to prevent the occurrence <strong>of</strong> HCC has yet to<br />
be determined. In cirrhotic patients there seems to be<br />
no benefit, but a study including patients with advanced<br />
liver fibrosis or cirrhosis showed a reduction in HCC<br />
in lamivudine treated patients compared to placebo.<br />
Patients with lower fibrosis and Child-Pugh scores were<br />
less prone to disease progression [50] . The data suggest<br />
nucleos(t)ide analogue therapy has to be initiated before<br />
the development <strong>of</strong> cirrhosis to prevent HCC and has to<br />
be continued indefinitely [50,62] .<br />
TREATMENT WITH NUCLEOSIDE/<br />
NUCLEOTIDE ANALOGUES<br />
Four oral nucleoside or nucleotide analogues, lamivudine,<br />
adefovir, entecavir and telbivudine, are currently marketed<br />
and approved as a first line <strong>of</strong> therapy for the treatment <strong>of</strong><br />
chronic hepatitis B. All therapies result in reduction <strong>of</strong> viral<br />
load, ALT levels and improvement <strong>of</strong> liver histology (Table 2).<br />
It is difficult to point out one compound which should be<br />
the first nucleoside or nucleotide used for the treatment<br />
<strong>of</strong> chronic hepatitis B. At least two major points at least<br />
have to be taken into account: (1) efficacy <strong>of</strong> the treatment<br />
on the short and long term, including the development<br />
<strong>of</strong> resistance and (2) the costs. Comparing the efficacy <strong>of</strong><br />
treatment is difficult; however, some comparative studies<br />
have been performed. Both entecavir and telbivudine<br />
proved superior efficacy over lamivudine after 1 year <strong>of</strong><br />
treatment [13,15,63,64] . Direct comparison <strong>of</strong> telbivudine or<br />
adefovir for 52 wk showed superior efficacy on viral and<br />
biochemical parameters for telbivudine, but resistance<br />
was not assessed [65] . Adefovir has not directly been<br />
compared to lamivudine. Direct comparison <strong>of</strong> entecavir<br />
and adefovir for a duration <strong>of</strong> 24 wk showed a decline<br />
<strong>of</strong> HBV DNA <strong>of</strong> 6.97 log10 copies/mL for entecavir and<br />
4.84 log10 copies/mL for adefovir. PCR undetectability<br />
(HBV < 300 copies/mL) was reached in 45% <strong>of</strong> entecavir<br />
treated patients vs 13% <strong>of</strong> those receiving adefovir [66] .<br />
Ten<strong>of</strong>ovir looks a promising new drug, but is only used in<br />
small series in lamivudine or adefovir treatment failures.<br />
The long term outcomes are only known for lamivudine<br />
and adefovir. Another problem with interpretation and<br />
positioning <strong>of</strong> the outcomes <strong>of</strong> clinical studies is the lack<br />
<strong>of</strong> standardisation <strong>of</strong> outcome measures.<br />
The development <strong>of</strong> resistance is the most important<br />
factor for loss <strong>of</strong> efficacy. Lamivudine has a high rate <strong>of</strong><br />
resistance <strong>of</strong> <strong>18</strong>%-27% after 1 year and this increases over<br />
time, being 44% at year 2, 60% at year 3, and after 4 years<br />
<strong>of</strong> treatment almost 70% has developed resistance [5,67-73] .<br />
Adefovir showed no resistance after 1 year, but rates<br />
increased to 1%-3%, 11%, <strong>18</strong>% and 28% at year 2, 3, 4<br />
and 5 [14,16,74] . Entecavir showed no resistance up to 2 years<br />
<strong>of</strong> treatment; however, complete non-responders did not<br />
receive treatment in year 2 [75] . Telbivudine had a resistance<br />
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2558 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Table 4 Treatment outcomes after 1 year <strong>of</strong> treatment for different antiviral drugs for the management <strong>of</strong> lamivudine resistant chronic<br />
hepatitis B for both HBeAg positive and HBeAg negative patients<br />
HBeAg pos<br />
www.wjgnet.com<br />
n Author; <strong>Journal</strong>; Yr HBeAg<br />
loss<br />
(%)<br />
PEG-IFN-α 2b 16 Leemans; J Hepatology;<br />
2006 [38]<br />
Adefovir 45 Buti; Hepatology;<br />
2004 [165]<br />
Adefovir 19 Peters; <strong>Gastroenterology</strong>;<br />
2004 [1<strong>18</strong>]<br />
HBeAg neg<br />
PEG-IFN-α 2b 20 Vassiliadis; WJG;<br />
2006 [39]<br />
Adefovir 75 Buti; Hepatology;<br />
2004 [165]<br />
Adefovir 20 Manilakopoulos;<br />
Hepatology; 2005 [119]<br />
Adefovir + lamivudine 44 Manilakopoulos;<br />
Hepatol; 2005 [119]<br />
Adefovir 26 Koskinas; J Hepatology;<br />
2005 [166]<br />
Adefovir + lamivudine 74 Lampertico; Hepatology;<br />
2005 [167]<br />
Adefovir + lamivudine 23 Koskinas; J Hepatology;<br />
2006 [166]<br />
Adefovir + lamivudine 49 Vassiliadis; AP&T;<br />
2005 [168]<br />
Mixed<br />
Adefovir <strong>18</strong> van Bömmel;<br />
Hepatology; 2004 [17]<br />
Adefovir + lamivudine 20 Peters; <strong>Gastroenterology</strong>;<br />
2004 [1<strong>18</strong>]<br />
Adefovir 57 Lee; Hepatology;<br />
2006 [102]<br />
Adefovir + lamivudine 46 Perrillo;<br />
<strong>Gastroenterology</strong>; 2004 [61]<br />
Adefovir ± lamivudine 11 126 Schiff; Hepatology;<br />
2003 [59]<br />
Adefovir + lamivudine 34 Moriconi; J Hepatology;<br />
2006 [169]<br />
Adefovir ± lamivudine 65 Hann; J Hepatology;<br />
2006 [132]<br />
Entecavir 42 Chang; <strong>Gastroenterology</strong>;<br />
2005 [170]<br />
HBeAg HBsAg<br />
serocon-version loss<br />
(%)<br />
(%)<br />
Decline viral<br />
load (log10<br />
copies/mL)<br />
13 13 6 0.6 6 4<br />
13 0 33 7<br />
16 11 4.0 26 5<br />
HBV DNA<br />
negativity<br />
(%)<br />
5 4<br />
0 51 7<br />
ALT<br />
normalisation<br />
(%)<br />
19<br />
51<br />
Histological<br />
improvement<br />
(%)<br />
47 0<br />
10<br />
63<br />
3.3 72 5<br />
3.3 87 0<br />
2.5 92 4<br />
78 6<br />
82 0<br />
2.8 87 0<br />
0 6.5 57 4<br />
19 0 2.8 44 4<br />
17 6 3.6 35 5<br />
20 2.4 19 3<br />
15 8 0 4.6 20 1<br />
7 10<br />
4.1 81 4<br />
68 1<br />
2.4 21 5<br />
11 4 5.6 26 4<br />
Entecavir 141 Sherman;<br />
<strong>Gastroenterology</strong>; 2006 [129]<br />
10 11 5.1 27 2<br />
Entecavir 42 Karino; J Hepatology;<br />
2006 [171]<br />
Entecavir 116 Yao; J Hepatology;<br />
2006 [172]<br />
Ten<strong>of</strong>ovir ± lamivudine 9 35 van Bömmel;<br />
Hepatology; 2004 [17]<br />
Ten<strong>of</strong>ovir ± lamivudine 44 Hann; J Hepatology;<br />
2006 [132]<br />
Ten<strong>of</strong>ovir + lamivudine 9 11 Van der Eijk;<br />
J Viral Hepatitis; 2005 [173]8<br />
Ten<strong>of</strong>ovir 9<br />
Ten<strong>of</strong>ovir 9<br />
Ten<strong>of</strong>ovir 9<br />
Ten<strong>of</strong>ovir 9<br />
10 Dore; J Infect Dis;<br />
2004 [174]<br />
12 Núñez; Aids;<br />
[175] 8<br />
2002<br />
20 Nelson; Aids;<br />
2003 [176]<br />
12 Benhamou; NEJM;<br />
2003 [177]<br />
15 3.8 60 4<br />
8 6 5.8 27 2<br />
4 10<br />
5.5 100 4<br />
5.0 86 5<br />
10 0 0 5.0 91<br />
20 10 4.9 25<br />
11 8 3.8 58 1<br />
25 4.0<br />
0 0 0 3.8<br />
75<br />
53 0<br />
60 <strong>18</strong><br />
30<br />
76 0<br />
68 0<br />
61 55 7<br />
78 60 0<br />
85<br />
Resistance<br />
(%)<br />
Efficacy measures presented are <strong>of</strong>f-treatment responses for PEG-interferon and on-treatment responses for nucleos(t)ide analogues. 1 LLD 200 copies/mL; 2 LLD<br />
300 copies/mL; 3 LLD 366 copies/mL; 4 LLD 400 copies/mL; 5 LLD 1.0 × 10 3 copies/mL; 6 LLD 2.0 × 10 3 copies/mL ; 7 LLD 1.0 × 10 5 copies/mL; 8 results after 24 wk<br />
<strong>of</strong> treatment; 9 including HIV/HBV co-infected patients ± some patients with, some patients without combination therapy; 10 after 24 mo <strong>of</strong> treatment; 11 patients<br />
with decompensated cirrhosis.<br />
0
Leemans WF et al . Management <strong>of</strong> chronic HBV 2559<br />
rate <strong>of</strong> 2%-4% after 1 year <strong>of</strong> treatment [63,65] .<br />
With long-ter m lamivudine treatment HBeAg<br />
seroconversion increases to 27%, 40%, 47% and 50% at<br />
year 2, 3, 4 and 5, respectively, despite the development<br />
<strong>of</strong> resistance [67,71,73,76] . Prolonged therapy with adefovir<br />
in HBeAg positive subjects resulted in viral load below<br />
10 3 copies/mL in 28% at year 1, 45% and 56% at year 2<br />
and 3. ALT levels became normal in 48%, 71% and 81%<br />
after 1, 2 and 3 years <strong>of</strong> treatment. Rates <strong>of</strong> HBeAg-loss<br />
increased to 42% and 52% and HBeAg seroconversion<br />
rates increased to 29% and 43% at year 2 and 3 [77] . A<br />
study with continued treatment up to 2 years showed an<br />
increase in viral reduction from -4.5 to -5.0 log10 copies/<br />
mL, increased in PCR-negativity (lower limit <strong>of</strong> detection<br />
300 copies/mL) from 28% to 42%, but the percentage<br />
<strong>of</strong> ALT normalisation remained unchanged (79% to<br />
78%). The percentage HBeAg-loss increased from 13%<br />
to 19% and the percentage <strong>of</strong> patients with HBeAg<br />
seroconversion increased to 15% [78] . In HBeAg negative<br />
subjects prolonged adefovir therapy <strong>of</strong> 2 years, showed<br />
little additional decline in viral load, but consolidated the<br />
response to adefovir as 71%-75% <strong>of</strong> the patients had a<br />
viral load below 10 3 copies/mL and ALT normalisation<br />
in 73%-79%. Long term treatment up to 5 years resulted<br />
in a viral load below 10 3 copies/ml in 78%-79% at year 3,<br />
65%-68% at year 4 and 67% after 5 years <strong>of</strong> continuous<br />
treatment. ALT levels were normal in 69%-78% at 3<br />
years, 70%-75% at 4 years and 69% after 5 years [74] . Also<br />
entecavir showed a continuous viral decline in patients<br />
with detectable HBV DNA beyond wk 48 and HBeAg<br />
seroconversion rates increased [79,80] . Another aspect which<br />
is little studied is the sustainability <strong>of</strong> response after<br />
discontinuation <strong>of</strong> therapy. In HBeAg positive subjects<br />
who seroconverted during therapy, response is durable<br />
in over half <strong>of</strong> the subjects [13,81-84] . In HBeAg positive<br />
patients treated with lamivudine who discontinued after<br />
achieving a complete response (HBeAg loss, undetectable<br />
HBV DNA and normal ALT) had a sustained response <strong>of</strong><br />
78%, 72%, 70%, 67% and 64% after 1, 2, 3, 4 and 5 years<br />
<strong>of</strong> follow-up, respectively [85] . In HBeAg positive subjects<br />
with HBeAg seroconversion during adefovir therapy the<br />
response was sustained in 91% [84] . In entecavir treated<br />
HBeAg positive subjects for 48 wk the sustained response<br />
(HBeAg loss and HBV DNA < 7.0 × 10 5 copies/mL)<br />
was 82% after a 24 wk follow-up [86] . The durability can be<br />
increased by continuing treatment for several months after<br />
HBeAg seroconversion. Therefore, it is recommended<br />
to continue treatment for at least 3-4 mo [82,83] . As many<br />
clinical trials had a predetermined endpoint, sustainability<br />
could be a bit higher if treatment was continued for a<br />
longer period in those patients who underwent HBeAg<br />
seroconversion within 3 mo before discontinuation. In<br />
HBeAg negative subjects the durability <strong>of</strong> response is<br />
<strong>of</strong>ten poor. Patients treated for two years with lamivudine<br />
who had undetectable HBV DNA levels (LLD 200<br />
copies/mL) discontinued treatment. After 12 mo <strong>of</strong><br />
follow-up the virological relapse rate was 50% [87] . The viral<br />
load at discontinuation and duration <strong>of</strong> treatment do not<br />
accurately predict sustainability <strong>of</strong> response in HBeAg<br />
negative patients.<br />
Other parameters such as intrahepatic total HBV DNA<br />
and intrahepatic cccDNA and HBcore expression and the<br />
level <strong>of</strong> hepatitis B virus core related antigen appear to<br />
be superior in prediction <strong>of</strong> sustained response compared<br />
to viral load at the end <strong>of</strong> therapy. The studies were,<br />
however, small and the results have not been confirmed by<br />
others [88,89] .<br />
MANAGEMENT OF TREATMENT FAILURES<br />
TO NUCLEOS(T)IDE ANALOGUES<br />
A distinction can be made for patients failing therapy:<br />
due to resistance or other reasons. Many patients do not<br />
achieve complete suppression <strong>of</strong> HBV DNA during<br />
treatment. Several factors may contribute such as noncompliance,<br />
inefficient conversion from the prodrug to<br />
its active metabolite, inadequate phosphorylation within<br />
the hepatocytes or underdosing <strong>of</strong> the drug. Some<br />
patients failing to respond initially to treatment may<br />
already harbour a resistant mutant prior to the start <strong>of</strong><br />
therapy [90,91] . Underdosing is particularly an issue with<br />
adefovir treatment as the 10 mg dose was chosen for safety<br />
reasons. The 30 mg dose was more effective, but also more<br />
nephrotoxic [16] .<br />
Little is known why some patients have suboptimal<br />
viral suppression. The known baseline predictors for<br />
response provide information on the likelihood <strong>of</strong><br />
response, but outcome cannot be predicted (Table 1). A<br />
high baseline viral load is probably one <strong>of</strong> the reasons why<br />
more HBeAg-positive patients have a suboptimal response<br />
compared to HBeAg-negative patients [13-16] . Recently,<br />
genotypic dependent polymorphisms have been described<br />
associated with primary treatment failure and more might<br />
be detected [91,92] . As viral factors, as well as host factors<br />
play an import role in response, it is difficult to assess the<br />
optimal treatment for sub-optimal responders. Presuming<br />
study randomisation led to an equal distribution <strong>of</strong> both<br />
viral and host factors, it is to be expected that more potent<br />
drugs are able to suppress viral replication in subjects<br />
with suboptimal suppression. Entecavir and telbivudine<br />
proved their superior potency over lamivudine in a head to<br />
head comparison and for telbivudine this observation also<br />
has been made in comparison with adefovir [13,15,63-65] . In<br />
adefovir treatment failures the more potent drug ten<strong>of</strong>ovir<br />
showed good viral suppression [93] . Patients responding<br />
to ten<strong>of</strong>ovir and switched to adefovir showed viral<br />
relapse, while no mutants could be detected [94] . Another<br />
strategy could be adding a second drug to the failing<br />
compound. In vitro testing demonstrated that combining<br />
adefovir with an L-nucleoside (lamivudine, telbivudine,<br />
emtricitabine) exerted additive antiviral effects [95] . Clinically<br />
the combination <strong>of</strong> adefovir and emtricitabine resulted in<br />
stronger viral suppression [96] . In patients failing adefovir<br />
switching therapy to ten<strong>of</strong>ovir and either emtricitabine<br />
or lamivudine resulted in decrease in viral load in most<br />
patients [97] .<br />
PREVENTION OF RESISTANCE<br />
For nucleoside/nucleotide analogue treatment, a number<br />
<strong>of</strong> risk factors for resistance have been identified. For<br />
lamivudine this includes: prior course <strong>of</strong> lamivudine,<br />
www.wjgnet.com
Leemans WF et al . Management <strong>of</strong> chronic HBV 2561<br />
therefore, more frequently in lamivudine resistant patients.<br />
After 1 year 1.4% <strong>of</strong> patients became resistant increasing<br />
up to 9% after two years and 15%-19% after 3 years <strong>of</strong><br />
treatment [75,129,130] .<br />
Ten<strong>of</strong>ovir disoproxil fumarate possesses potent activity<br />
against lamivudine resistant hepatitis B (Table 4) [17,93,131,132] .<br />
Lamivudine resistant mutants lead to a slight 1.8-5.7 fold<br />
increase in IC50 values. The known mutants however,<br />
remain sensitive to ten<strong>of</strong>ovir and the mutation pattern<br />
<strong>of</strong> ten<strong>of</strong>ovir has no overlap with the mutational pattern<br />
<strong>of</strong> lamivudine [121,123,133] . Most studies add ten<strong>of</strong>ovir to<br />
lamivudine, though ten<strong>of</strong>ovir mono therapy seems to be<br />
equally effective [134] . Ten<strong>of</strong>ovir is thought to be a more<br />
potent viral suppressing agent for lamivudine resistant<br />
HBV compared to adefovir, but its efficacy is only<br />
investigated in relatively small groups <strong>of</strong> patients. Many <strong>of</strong><br />
them including HIV-HBV co-infected patients [17,132] . Being<br />
a very promising drug, more studies have to be conducted<br />
to determine the exact role or the combination with other<br />
compounds for the treatment <strong>of</strong> lamivudine resistant<br />
hepatitis B.<br />
Adefovir resistance<br />
Adefovir resistant strains are susceptible to lamivudine<br />
and lamivudine can thus be used for rescue therapy [135] .<br />
Indeed clinically lamivudine is able to reduce the viral load<br />
in adefovir resistant patients [136,137] . The effect <strong>of</strong> adefovir<br />
associated mutations on long-term treatment is unknown.<br />
It is likely that lamivudine resistant strains severely limit<br />
the use <strong>of</strong> lamivudine. In vitro a strain conferring resistance<br />
to both adefovir and lamivudine is viable and has reduced<br />
sensitivity to all common drugs used for hepatitis B,<br />
although ten<strong>of</strong>ovir and entecavir are likely to be able to<br />
suppress HBV DNA [135] . Adefovir resistant strains are<br />
susceptible to entecavir and ten<strong>of</strong>ovir in vitro [135,138] . In<br />
very small series ten<strong>of</strong>ovir and entecavir proved effective<br />
against adefovir resistant HBV [101,139] .<br />
Entecavir resistance<br />
Entecavir resistance is highly cross-resistant with lamivudine<br />
as entecavir resistance requires lamivudine resistance [127] .<br />
This mutant strain is sensitive in vitro to adefovir and clinical<br />
treatment with adefovir resulted in decline <strong>of</strong> the viral<br />
load [127,140] .<br />
Future directions for the management <strong>of</strong> resistance<br />
The development <strong>of</strong> resistance is the largest limiting<br />
factor for long-term treatment with nucleoside or<br />
nucleotide analogues and should therefore be studied in<br />
detail. Lamivudine as well as many other L-nucleosides<br />
have high rates <strong>of</strong> resistance caused by a single mutation.<br />
Due to the high resistance rate and being the only oral<br />
drug available for a long time it gave the opportunity to<br />
study the mechanisms and outcomes <strong>of</strong> resistance. The<br />
large number <strong>of</strong> patients treated with lamivudine with<br />
subsequent development <strong>of</strong> resistance made it possible to<br />
study the effect <strong>of</strong> salvage therapy. Entecavir and adefovir<br />
proved their efficacy in large populations. But despite<br />
all these opportunities we still do not know the exact<br />
incidence <strong>of</strong> adefovir resistance in lamivudine resistant<br />
patients. Although the balance tips to lamivudine and<br />
adefovir combination therapy over adefovir monotherapy,<br />
the definite answers have not been provided, especially<br />
the question whether monotherapy comes with higher<br />
rates <strong>of</strong> resistance. Ten<strong>of</strong>ovir looks very promising,<br />
although studies are small and little is known on the<br />
effect <strong>of</strong> ten<strong>of</strong>ovir monotherapy on lamivudine resistant<br />
strains. Very little data is available on the occurrence and<br />
management <strong>of</strong> adefovir and entecavir as well as newer<br />
drugs. Studying resistance for compounds with low rates<br />
is difficult as large numbers have to be treated. Large<br />
scale initiatives are necessary to study the effectiveness<br />
and resistance. Insight in the mutational patterns is<br />
very important as each pattern has its own influence on<br />
replication fitness and cross-resistance. In vitro studies<br />
and molecular modelling have to provide these answers<br />
to design optimal treatment regimens. This approach is<br />
needed as many drugs have been developed and it is not<br />
feasible to test all drugs or combinations for all mutational<br />
patterns.<br />
CONCLUSION<br />
The knowledge and therapeutic options have come a long<br />
way since the discovery <strong>of</strong> the hepatitis B virus. Today<br />
chronic hepatitis B virus infection is a treatable disease.<br />
However, much remains unknown and treatment options<br />
are far from perfect. The natural history is only partially<br />
understood and only recently the importance <strong>of</strong> viral load<br />
has been revealed [19-21] . Further studies have to identify<br />
the factors involved in progression <strong>of</strong> disease in order to<br />
be able to identify those patients in need <strong>of</strong> treatment.<br />
Treatment options are diverse and have limitations in<br />
tolerability and efficacy. More data are needed to be able<br />
to predict treatment outcome in patients. This is especially<br />
important for treatment with interferon, which is costly<br />
and is associated with considerable side effects and an<br />
overall success rate between 30%-40%. However, this<br />
treatment has proven to be able to inactivate the disease for<br />
long periods in responders, which might result in HBsAgseroconversion.<br />
Research to identify those patients likely<br />
to respond before start <strong>of</strong> therapy or within a few weeks<br />
after start <strong>of</strong> treatment is urgently needed. Nucleoside<br />
or nucleotide analogue therapy is the alternative for<br />
interferon based treatments and the response rates on<br />
treatment are higher compared to interferon. However,<br />
relapse is frequent after discontinuation, while identifying<br />
those relapsing is not possible. This has resulted in longterm<br />
treatment, although it is known that response can<br />
be sustained <strong>of</strong>f-treatment. By identifying the factors<br />
responsible for sustained response it might be possible to<br />
accurately predict sustainability. In theory this could result<br />
in nucleos(t)ide analogue therapy <strong>of</strong> limited duration. This<br />
is especially important in young adults who <strong>of</strong>ten have a<br />
desire for pregnancy, whilst the antiviral drugs have not<br />
been investigated on safety for the unborn child or long<br />
term in patients themselves.<br />
Data on treatment efficacy in treatment experienced<br />
patients is limited. Therefore, large cohorts <strong>of</strong> patients<br />
have to be studied. Especially the rate <strong>of</strong> resistance and the<br />
mutational patterns are hard to assess. For some therapies<br />
resistance rates are low or mutational patterns are diverse.<br />
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2562 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Genotypic and phenotypic testing and molecular modelling<br />
are helpful to determine the level <strong>of</strong> cross-resistance with<br />
other compounds. Promising rescue therapies should<br />
be studied clinically in order to determine their efficacy.<br />
The data on resistance (mutational patterns, replication<br />
fitness, molecular modelling and cross resistance) is<br />
scattered, and therefore, it is almost impossible to look up<br />
the implications <strong>of</strong> a specific mutational pattern. A large<br />
central database combining all the data on resistance could<br />
provide this information and would be <strong>of</strong> great value for<br />
everyone interpreting mutational patterns. This database<br />
could also provide clinicians advice on treatment for an<br />
individual resistant patient. More specific knowledge on<br />
resistance calls for the development <strong>of</strong> new techniques<br />
that are sensitive, able to detect new variants, able to<br />
determine if multiple variants are located on the same<br />
genome, easy to perform and interpret, cheap and suitable<br />
for mass screening.<br />
As none <strong>of</strong> the current treatments for chronic hepatitis<br />
B is optimal, prevention <strong>of</strong> infection should be one <strong>of</strong><br />
the cornerstones <strong>of</strong> management <strong>of</strong> chronic hepatitis<br />
B. Safe and well tolerated vaccines for hepatitis B have<br />
been developed and their effectiveness have been proved.<br />
There have been some concerns about the luxation <strong>of</strong><br />
autoimmune phenomena [141] . Three WHO large scale<br />
evaluations revealed no increased risk for the development<br />
<strong>of</strong> autoimmune diseases [142-144] .<br />
In conclusion: The management <strong>of</strong> chronic hepatitis B<br />
has evolved fast and nowadays hepatitis B is a treatable<br />
disease. More research on the factors involved in response<br />
to treatment or treatment failure is needed to tailor<br />
treatment to the individual patient. Much attention should<br />
be paid to universal worldwide vaccination as this may<br />
significantly change the burden <strong>of</strong> disease.<br />
REFERENCES<br />
1 Kane M. Global programme for control <strong>of</strong> hepatitis B<br />
infection. Vaccine 1995; 13 Suppl 1: S47-S49<br />
2 de Franchis R, Hadengue A, Lau G, Lavanchy D, Lok A,<br />
McIntyre N, Mele A, Paumgartner G, Pietrangelo A, Rodes<br />
J, Rosenberg W, Valla D. EASL International Consensus<br />
Conference on Hepatitis B. 13-14 September, 2002 Geneva,<br />
Switzerland. Consensus statement (long version). J Hepatol<br />
2003; 39 Suppl 1: S3-S25<br />
3 Janssen HL, van Zonneveld M, Senturk H, Zeuzem S, Akarca<br />
US, Cakaloglu Y, Simon C, So TM, Gerken G, de Man RA,<br />
Niesters HG, Zondervan P, Hansen B, Schalm SW. Pegylated<br />
interferon alfa-2b alone or in combination with lamivudine for<br />
HBeAg-positive chronic hepatitis B: a randomised trial. Lancet<br />
2005; 365: 123-129<br />
4 Lau GK, Piratvisuth T, Luo KX, Marcellin P, Thongsawat S,<br />
Cooksley G, Gane E, Fried MW, Chow WC, Paik SW, Chang<br />
WY, Berg T, Flisiak R, McCloud P, Pluck N. Peginterferon<br />
Alfa-2a, lamivudine, and the combination for HBeAg-positive<br />
chronic hepatitis B. N Engl J Med 2005; 352: 2682-2695<br />
5 Marcellin P, Lau GK, Bonino F, Farci P, Hadziyannis S, Jin<br />
R, Lu ZM, Piratvisuth T, Germanidis G, Yurdaydin C, Diago<br />
M, Gurel S, Lai MY, Button P, Pluck N. Peginterferon alfa-<br />
2a alone, lamivudine alone, and the two in combination in<br />
patients with HBeAg-negative chronic hepatitis B. N Engl J<br />
Med 2004; 351: 1206-1217<br />
6 Niederau C, Heintges T, Lange S, Goldmann G, Niederau<br />
CM, Mohr L, Haussinger D. Long-term follow-up <strong>of</strong> HBeAgpositive<br />
patients treated with interferon alfa for chronic<br />
www.wjgnet.com<br />
hepatitis B. N Engl J Med 1996; 334: 1422-1427<br />
7 Bortolotti F, Jara P, Barbera C, Gregorio GV, Vegnente A,<br />
Zancan L, Hierro L, Crivellaro C, Vergani GM, Iorio R, Pace<br />
M, Con P, Gatta A. Long term effect <strong>of</strong> alpha interferon in<br />
children with chronic hepatitis B. Gut 2000; 46: 715-7<strong>18</strong><br />
8 Papatheodoridis GV, Manesis E, Hadziyannis SJ. The longterm<br />
outcome <strong>of</strong> interferon-alpha treated and untreated<br />
patients with HBeAg-negative chronic hepatitis B. J Hepatol<br />
2001; 34: 306-313<br />
9 Brunetto MR, Oliveri F, Coco B, Leandro G, Colombatto P,<br />
Gorin JM, Bonino F. Outcome <strong>of</strong> anti-HBe positive chronic<br />
hepatitis B in alpha-interferon treated and untreated patients:<br />
a long term cohort study. J Hepatol 2002; 36: 263-270<br />
10 Liaw YF, Sheen IS, Chen TJ, Chu CM, Pao CC. Incidence,<br />
determinants and significance <strong>of</strong> delayed clearance <strong>of</strong> serum<br />
HBsAg in chronic hepatitis B virus infection: a prospective<br />
study. Hepatology 1991; 13: 627-631<br />
11 McMahon BJ, Alberts SR, Wainwright RB, Bulkow L, Lanier<br />
AP. Hepatitis B-related sequelae. Prospective study in 1400<br />
hepatitis B surface antigen-positive Alaska native carriers.<br />
Arch Intern Med 1990; 150: 1051-1054<br />
12 Huo TI, Wu JC, Lee PC, Chau GY, Lui WY, Tsay SH, Ting<br />
LT, Chang FY, Lee SD. Sero-clearance <strong>of</strong> hepatitis B surface<br />
antigen in chronic carriers does not necessarily imply a good<br />
prognosis. Hepatology 1998; 28: 231-236<br />
13 Chang TT, Gish RG, de Man R, Gadano A, Sollano J, Chao YC,<br />
Lok AS, Han KH, Goodman Z, Zhu J, Cross A, DeHertogh D,<br />
Wilber R, Colonno R, Apelian D. A comparison <strong>of</strong> entecavir<br />
and lamivudine for HBeAg-positive chronic hepatitis B. N<br />
Engl J Med 2006; 354: 1001-1010<br />
14 Hadziyannis SJ, Tassopoulos NC, Heathcote EJ, Chang<br />
TT, Kitis G, Rizzetto M, Marcellin P, Lim SG, Goodman Z,<br />
Wulfsohn MS, Xiong S, Fry J, Brosgart CL. Adefovir dipivoxil<br />
for the treatment <strong>of</strong> hepatitis B e antigen-negative chronic<br />
hepatitis B. N Engl J Med 2003; 348: 800-807<br />
15 Lai CL, Shouval D, Lok AS, Chang TT, Cheinquer H,<br />
Goodman Z, DeHertogh D, Wilber R, Zink RC, Cross A,<br />
Colonno R, Fernandes L. Entecavir versus lamivudine for<br />
patients with HBeAg-negative chronic hepatitis B. N Engl J<br />
Med 2006; 354: 1011-1020<br />
16 Marcellin P, Chang TT, Lim SG, Tong MJ, Sievert W, Shiffman<br />
ML, Jeffers L, Goodman Z, Wulfsohn MS, Xiong S, Fry J,<br />
Brosgart CL. Adefovir dipivoxil for the treatment <strong>of</strong> hepatitis<br />
B e antigen-positive chronic hepatitis B. N Engl J Med 2003;<br />
348: 808-816<br />
17 van Bommel F, Wunsche T, Mauss S, Reinke P, Bergk A,<br />
Schurmann D, Wiedenmann B, Berg T. Comparison <strong>of</strong><br />
adefovir and ten<strong>of</strong>ovir in the treatment <strong>of</strong> lamivudine-resistant<br />
hepatitis B virus infection. Hepatology 2004; 40: 1421-1425<br />
<strong>18</strong> Cooksley WG, Piratvisuth T, Lee SD, Mahachai V, Chao YC,<br />
Tanwandee T, Chutaputti A, Chang WY, Zahm FE, Pluck N.<br />
Peginterferon alpha-2a (40 kDa): an advance in the treatment<br />
<strong>of</strong> hepatitis B e antigen-positive chronic hepatitis B. J Viral<br />
Hepat 2003; 10: 298-305<br />
19 Chen G, Lin W, Shen F, Iloeje UH, London WT, Evans AA.<br />
Past HBV viral load as predictor <strong>of</strong> mortality and morbidity<br />
from HCC and chronic liver disease in a prospective study.<br />
Am J Gastroenterol 2006; 101: 1797-<strong>18</strong>03<br />
20 Iloeje UH, Yang HI, Su J, Jen CL, You SL, Chen CJ. Predicting<br />
cirrhosis risk based on the level <strong>of</strong> circulating hepatitis B viral<br />
load. <strong>Gastroenterology</strong> 2006; 130: 678-686<br />
21 Yu MW, Yeh SH, Chen PJ, Liaw YF, Lin CL, Liu CJ, Shih WL,<br />
Kao JH, Chen DS, Chen CJ. Hepatitis B virus genotype and<br />
DNA level and hepatocellular carcinoma: a prospective study<br />
in men. J Natl Cancer Inst 2005; 97: 265-272<br />
22 Yalcin K, Degertekin H, Kokoglu OF, Ayaz C. A three-month<br />
course <strong>of</strong> lamivudine therapy in HBeAg-positive hepatitis<br />
B patients with normal aminotransferase levels. Turk J<br />
Gastroenterol 2004; 15: 14-20<br />
23 Kao JH, Wu NH, Chen PJ, Lai MY, Chen DS. Hepatitis B<br />
genotypes and the response to interferon therapy. J Hepatol<br />
2000; 33: 998-1002<br />
24 Wai CT, Chu CJ, Hussain M, Lok AS. HBV genotype B is
Leemans WF et al . Management <strong>of</strong> chronic HBV 2563<br />
associated with better response to interferon therapy in<br />
HBeAg(+) chronic hepatitis than genotype C. Hepatology 2002;<br />
36: 1425-1430<br />
25 Erhardt A, Blondin D, Hauck K, Sagir A, Kohnle T, Heintges<br />
T, Haussinger D. Response to interferon alfa is hepatitis B<br />
virus genotype dependent: genotype A is more sensitive to<br />
interferon than genotype D. Gut 2005; 54: 1009-1013<br />
26 Flink HJ, van Zonneveld M, Hansen BE, de Man RA, Schalm<br />
SW, Janssen HL. Treatment with Peg-interferon alpha-2b for<br />
HBeAg-positive chronic hepatitis B: HBsAg loss is associated<br />
with HBV genotype. Am J Gastroenterol 2006; 101: 297-303<br />
27 Hadziyannis S, Lau G, Marcellin P, Piratvisuth T, Cooksley<br />
G, Bonino F, Chutaputti A, Diago M, Jin R, Pluck N. Sustained<br />
HBsAg seroconversion in patients with chronic hepatitis<br />
B treated with Peginterferon α-2a (40 kDa) (Pegasys®). J<br />
Hepatology 2005; 42 Suppl 2: 178<br />
28 Bonino F, Lau G, Marcellin P, Hadziyannis S, Kitis G, Jin R,<br />
Yao GB, Piratvisuth T, Germanidis G, Yurdaydin C, Diago M,<br />
Gurel S, Lai MY, McCloud P, Brunetto MR, Farci P. The first<br />
detailed analysis <strong>of</strong> pedictors <strong>of</strong> response in HBeAg-negative<br />
chronic hepatitis B: data from a multicenter, randomized,<br />
partially double-blin study <strong>of</strong> peginterferon-alfa-2a (40-KD)<br />
(Pegasys®) alone or in combination with lamivudine vs<br />
lamivudine alone. Hepatology 2004; 40 Suppl 1: 659A<br />
29 Marcellin P, Bonino F, Lau GK, Farci P, Yurdaydin C,<br />
Piratvisuth T, Luo K, Gurel S, Hadziyannis S, Wang Y,<br />
Popescu M. Suppression <strong>of</strong> HBV DNA in patients with<br />
HBeAg-negative CHB treated with PEG-Interferon alfa-2a (40<br />
kD) +/- lamivudine: 2-year follow-up results. Hepatology 2006;<br />
44 Suppl 1: 550A<br />
30 Lok AS, Heathcote EJ, Ho<strong>of</strong>nagle JH. Management <strong>of</strong> hepatitis<br />
B: 2000--summary <strong>of</strong> a workshop. <strong>Gastroenterology</strong> 2001; 120:<br />
<strong>18</strong>28-<strong>18</strong>53<br />
31 Westland C, Delaney W 4th, Yang H, Chen SS, Marcellin P,<br />
Hadziyannis S, Gish R, Fry J, Brosgart C, Gibbs C, Miller M,<br />
Xiong S. Hepatitis B virus genotypes and virologic response<br />
in 694 patients in phase III studies <strong>of</strong> adefovir dipivoxil1.<br />
<strong>Gastroenterology</strong> 2003; 125: 107-116<br />
32 Yurdaydin C, Senturk H, Boron-Kaczmarska A, Raptopoulou-<br />
Gigi M, Batur Y, Goodman Z, Vaughan J, Brett-Smith H,<br />
Hindes R. Entecavir (ETV) demonstrates consistent responses<br />
throughout baseline disease and demographic subgroups for<br />
the treatment <strong>of</strong> lamivudine-refractory HBeAg(+) patients<br />
with chronic hepatitis B. J Hepatology 2006; 44 Suppl 2:<br />
S190-S191<br />
33 Lampertico P, Del Ninno E, Vigano M, Romeo R, Donato MF,<br />
Sablon E, Morabito A, Colombo M. Long-term suppression <strong>of</strong><br />
hepatitis B e antigen-negative chronic hepatitis B by 24-month<br />
interferon therapy. Hepatology 2003; 37: 756-763<br />
34 Manesis EK, Hadziyannis SJ. Interferon alpha treatment and<br />
retreatment <strong>of</strong> hepatitis B e antigen-negative chronic hepatitis<br />
B. <strong>Gastroenterology</strong> 2001; 121: 101-109<br />
35 Wong DK, Cheung AM, O'Rourke K, Naylor CD, Detsky AS,<br />
Heathcote J. Effect <strong>of</strong> alpha-interferon treatment in patients<br />
with hepatitis B e antigen-positive chronic hepatitis B. A metaanalysis.<br />
Ann Intern Med 1993; 119: 312-323<br />
36 Schiff ER, Dienstag JL, Karayalcin S, Grimm IS, Perrillo RP,<br />
Husa P, de Man RA, Goodman Z, Condreay LD, Crowther<br />
LM, Woessner MA, McPhillips PJ, Brown NA. Lamivudine<br />
and 24 weeks <strong>of</strong> lamivudine/interferon combination therapy<br />
for hepatitis B e antigen-positive chronic hepatitis B in<br />
interferon nonresponders. J Hepatol 2003; 38: 8<strong>18</strong>-826<br />
37 Hui CK, Zhang HY, Lau GK. Management <strong>of</strong> chronic hepatitis<br />
B in treatment-experienced patients. Gastroenterol Clin North<br />
Am 2004; 33: 601-616, x<br />
38 Leemans WF, Flink HJ, Janssen HL, Niesters HG, Schalm SW,<br />
de Man RA. The effect <strong>of</strong> pegylated interferon-alpha on the<br />
treatment <strong>of</strong> lamivudine resistant chronic HBeAg positive<br />
hepatitis B virus infection. J Hepatol 2006; 44: 507-511<br />
39 Vassiliadis T, Patsiaoura K, Tziomalos K, Gkiourtzis T,<br />
Giouleme O, Grammatikos N, Rizopoulou D, Nikolaidis<br />
N, Katsinelos P, Orfanou-Koumerkeridou E, Eugenidis N.<br />
Pegylated IFN-alpha 2b added to ongoing lamivudine therapy<br />
in patients with lamivudine-resistant chronic hepatitis B.<br />
<strong>World</strong> J Gastroenterol 2006; 12: 2417-2422<br />
40 de Jongh FE, Janssen HL, de Man RA, Hop WC, Schalm<br />
SW, van Blankenstein M. Survival and prognostic indicators<br />
in hepatitis B surface antigen-positive cirrhosis <strong>of</strong> the liver.<br />
<strong>Gastroenterology</strong> 1992; 103: 1630-1635<br />
41 Fattovich G, Giustina G, Schalm SW, Hadziyannis S, Sanchez-<br />
Tapias J, Almasio P, Christensen E, Krogsgaard K, Degos F,<br />
Carneiro de Moura M. Occurrence <strong>of</strong> hepatocellular carcinoma<br />
and decompensation in western European patients with<br />
cirrhosis type B. The EUROHEP Study Group on Hepatitis B<br />
Virus and Cirrhosis. Hepatology 1995; 21: 77-82<br />
42 Realdi G, Fattovich G, Hadziyannis S, Schalm SW, Almasio<br />
P, Sanchez-Tapias J, Christensen E, Giustina G, Noventa<br />
F. Survival and prognostic factors in 366 patients with<br />
compensated cirrhosis type B: a multicenter study. The<br />
Investigators <strong>of</strong> the European Concerted Action on Viral<br />
Hepatitis (EUROHEP). J Hepatol 1994; 21: 656-666<br />
43 Lai CJ, Terrault NA. Antiviral therapy in patients with chronic<br />
hepatitis B and cirrhosis. Gastroenterol Clin North Am 2004; 33:<br />
629-654, x-xi<br />
44 Perrillo RP, Schiff ER, Davis GL, Bodenheimer HC Jr, Lindsay<br />
K, Payne J, Dienstag JL, O'Brien C, Tamburro C, Jacobson<br />
IM. A randomized, controlled trial <strong>of</strong> interferon alfa-2b alone<br />
and after prednisone withdrawal for the treatment <strong>of</strong> chronic<br />
hepatitis B. The Hepatitis Interventional Therapy Group. N<br />
Engl J Med 1990; 323: 295-301<br />
45 Lampertico P, Del Ninno E, Manzin A, Donato MF, Rumi<br />
MG, Lunghi G, Morabito A, Clementi M, Colombo M. A<br />
randomized, controlled trial <strong>of</strong> a 24-month course <strong>of</strong> interferon<br />
alfa 2b in patients with chronic hepatitis B who had hepatitis B<br />
virus DNA without hepatitis B e antigen in serum. Hepatology<br />
1997; 26: 1621-1625<br />
46 van Zonneveld M, Flink HJ, Verhey E, Senturk H, Zeuzem<br />
S, Akarca US, Cakaloglu Y, Simon C, So TM, Gerken G, de<br />
Man RA, Hansen BE, Schalm SW, Janssen HL. The safety<br />
<strong>of</strong> pegylated interferon alpha-2b in the treatment <strong>of</strong> chronic<br />
hepatitis B: predictive factors for dose reduction and treatment<br />
discontinuation. Aliment Pharmacol Ther 2005; 21: 1163-1171<br />
47 Dienstag JL, Schiff ER, Wright TL, Perrillo RP, Hann HW,<br />
Goodman Z, Crowther L, Condreay LD, Woessner M, Rubin M,<br />
Brown NA. Lamivudine as initial treatment for chronic hepatitis<br />
B in the United States. N Engl J Med 1999; 341: 1256-1263<br />
48 Lai CL, Chien RN, Leung NW, Chang TT, Guan R, Tai DI, Ng<br />
KY, Wu PC, Dent JC, Barber J, Stephenson SL, Gray DF. A oneyear<br />
trial <strong>of</strong> lamivudine for chronic hepatitis B. Asia Hepatitis<br />
Lamivudine Study Group. N Engl J Med 1998; 339: 61-68<br />
49 Schalm SW, Heathcote J, Cianciara J, Farrell G, Sherman<br />
M, Willems B, Dhillon A, Moorat A, Barber J, Gray DF.<br />
Lamivudine and alpha interferon combination treatment <strong>of</strong><br />
patients with chronic hepatitis B infection: a randomised trial.<br />
Gut 2000; 46: 562-568<br />
50 Liaw YF, Sung JJ, Chow WC, Farrell G, Lee CZ, Yuen H,<br />
Tanwandee T, Tao QM, Shue K, Keene ON, Dixon JS, Gray<br />
DF, Sabbat J. Lamivudine for patients with chronic hepatitis B<br />
and advanced liver disease. N Engl J Med 2004; 351: 1521-1531<br />
51 Schiff E, Lee WM, Chao Y-C, Sette H, Schalm SW, Brett-<br />
Smith H, Zink R. Efficacy and safety <strong>of</strong> entecavir (ETV) and<br />
lamivudine (LVD) in compensated, cirrhotic patients with<br />
chronic hepatitis B. Hepatology 2005; 42 Suppl 1: 583A-584A<br />
52 Ho<strong>of</strong>nagle JH, Di Bisceglie AM, Waggoner JG, Park Y.<br />
Interferon alfa for patients with clinically apparent cirrhosis<br />
due to chronic hepatitis B. <strong>Gastroenterology</strong> 1993; 104: 1116-1121<br />
53 Perrillo R, Tamburro C, Regenstein F, Balart L, Bodenheimer H,<br />
Silva M, Schiff E, Bodicky C, Miller B, Denham C. Low-dose,<br />
titratable interferon alfa in decompensated liver disease caused<br />
by chronic infection with hepatitis B virus. <strong>Gastroenterology</strong><br />
1995; 109: 908-916<br />
54 Villeneuve JP, Condreay LD, Willems B, Pomier-Layrargues<br />
G, Fenyves D, Bilodeau M, Leduc R, Peltekian K, Wong<br />
F, Margulies M, Heathcote EJ. Lamivudine treatment for<br />
decompensated cirrhosis resulting from chronic hepatitis B.<br />
Hepatology 2000; 31: 207-210<br />
www.wjgnet.com
2564 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
55 Yao FY, Bass NM. Lamivudine treatment in patients with<br />
severely decompensated cirrhosis due to replicating hepatitis<br />
B infection. J Hepatol 2000; 33: 301-307<br />
56 Yao FY, Terrault NA, Freise C, Maslow L, Bass NM.<br />
Lamivudine treatment is beneficial in patients with severely<br />
decompensated cirrhosis and actively replicating hepatitis<br />
B infection awaiting liver transplantation: a comparative<br />
study using a matched, untreated cohort. Hepatology 2001; 34:<br />
411-416<br />
57 Kapoor D, Guptan RC, Wakil SM, Kazim SN, Kaul R, Agarwal<br />
SR, Raisuddin S, Hasnain SE, Sarin SK. Beneficial effects<br />
<strong>of</strong> lamivudine in hepatitis B virus-related decompensated<br />
cirrhosis. J Hepatol 2000; 33: 308-312<br />
58 Perrillo RP, Wright T, Rakela J, Levy G, Schiff E, Gish R,<br />
Martin P, Dienstag J, Adams P, Dickson R, Anschuetz G, Bell S,<br />
Condreay L, Brown N. A multicenter United States-Canadian<br />
trial to assess lamivudine monotherapy before and after liver<br />
transplantation for chronic hepatitis B. Hepatology 2001; 33:<br />
424-432<br />
59 Schiff ER, Lai CL, Hadziyannis S, Neuhaus P, Terrault N,<br />
Colombo M, Tillmann HL, Samuel D, Zeuzem S, Lilly L,<br />
Rendina M, Villeneuve JP, Lama N, James C, Wulfsohn MS,<br />
Namini H, Westland C, Xiong S, Choy GS, Van Doren S, Fry<br />
J, Brosgart CL. Adefovir dipivoxil therapy for lamivudineresistant<br />
hepatitis B in pre- and post-liver transplantation<br />
patients. Hepatology 2003; 38: 1419-1427<br />
60 Schiff E, Lai CL, Neuhaus P, Tillman H, Samuel D, Villeneuve<br />
J, Hadziyannis S, Xiong S, Arterburn S, Brosgart C, Currie G.<br />
Adefovir dipivoxil (ADV provides significant clinical benefits,<br />
reduces MELD score and prevents liver transplantation in<br />
chronic hepatitis B patients wait-listed for liver transplantation<br />
(OLT) with lamivudine-resistance (LAM-R). J Hepatol 2005; 42<br />
Suppl 2: S5<br />
61 Perrillo R, Hann HW, Mutimer D, Willems B, Leung N, Lee<br />
WM, Moorat A, Gardner S, Woessner M, Bourne E, Brosgart<br />
CL, Schiff E. Adefovir dipivoxil added to ongoing lamivudine<br />
in chronic hepatitis B with YMDD mutant hepatitis B virus.<br />
<strong>Gastroenterology</strong> 2004; 126: 81-90<br />
62 Lampertico P, Vigano M, Manenti E, Iavarone M, Lunghi G,<br />
Colombo M. Five years <strong>of</strong> sequential LAM to LAM+ADV<br />
therapy suppresses HBV replication in most HBeAG-negative<br />
cirrhotics, preventing decompensation but not hepatocellular<br />
carcinoma. Hepatology 2005; 42 Suppl 1: 582A-583A<br />
63 Gane E, Lai CL, Liaw YF, Thongsawat S, Wang Y, Chen Y,<br />
Heathcote EJ, Rasenack J, Bzowej N, Naoumov NV, Chao G,<br />
Fielman B, Brown N. Phase III comparison <strong>of</strong> telbivudine vs<br />
lamivudine in HBeAg-positive patients with chronic hepatitis<br />
B; efficacy, safety and predictors <strong>of</strong> response at 1 year. J<br />
Hepatol 2006; 44 Suppl 2: S<strong>18</strong>3-S<strong>18</strong>4<br />
64 Yao G, Chen CJ, Lu W, Ren H, Tan D, Wang Y, Xu D, Jiang M,<br />
Liu J, Xu D, MacDonald L. Entecavir is superior to lamivudine<br />
for the treatment <strong>of</strong> chronic hepatitis B (CHB): results <strong>of</strong> a<br />
phase 3 Chinese study (ETV-023) in nucleoside-naïve patients.<br />
J Hepatol 2006; 44 Suppl 2: S193<br />
65 Bzowej N, Chan HLY, Lai C-L, Cho M, Moon YM, Chao Y-C,<br />
Heathcote EJ, Meyers R, Minuk G, G., Marcellin P, Jeffers<br />
L, Sievert W, Kaiser R, Harb G, Chao GC, Brown NA. A<br />
randomized trial <strong>of</strong> telbivudine (LDT) vs. adefovir for HBeAgpositive<br />
chronic hepatitis B: final 52 week results. Hepatology<br />
2006; 44 Suppl 1: 563A<br />
66 Leung N, Peng C-Y, Sollano J, Lesmana L, Yuen M-F, Jeffers L,<br />
Han H-W, Sherman M, Zhu J, Mencarini K, Colonno R, Cross A,<br />
Wilber R, Lopez-Talavera J-C. Entecavir results in higher HBV<br />
DNA reduction vs adefovir in chronically infected HBeAg(+)<br />
antiviral-naïve adults: 24 wk results (E.A.R.L.Y. study).<br />
Hepatology 2006; 44 Suppl 1: 554A<br />
67 Leung NW, Lai CL, Chang TT, Guan R, Lee CM, Ng KY, Lim<br />
SG, Wu PC, Dent JC, Edmundson S, Condreay LD, Chien<br />
RN. Extended lamivudine treatment in patients with chronic<br />
hepatitis B enhances hepatitis B e antigen seroconversion rates:<br />
results after 3 years <strong>of</strong> therapy. Hepatology 2001; 33: 1527-1532<br />
68 Hadziyannis SJ, Papatheodoridis GV, Dimou E, Laras<br />
A, Papaioannou C. Efficacy <strong>of</strong> long-term lamivudine<br />
www.wjgnet.com<br />
monotherapy in patients with hepatitis B e antigen-negative<br />
chronic hepatitis B. Hepatology 2000; 32: 847-851<br />
69 Buti M, Cotrina M, Jardi R, de Castro EC, Rodriguez-Frias<br />
F, Sanchez-Avila F, Esteban R, Guardia J. Two years <strong>of</strong><br />
lamivudine therapy in anti-HBe-positive patients with chronic<br />
hepatitis B. J Viral Hepat 2001; 8: 270-275<br />
70 Tassopoulos NC, Volpes R, Pastore G, Heathcote J, Buti<br />
M, Goldin RD, Hawley S, Barber J, Condreay L, Gray DF.<br />
Efficacy <strong>of</strong> lamivudine in patients with hepatitis B e antigennegative/hepatitis<br />
B virus DNA-positive (precore mutant)<br />
chronic hepatitis B.Lamivudine Precore Mutant Study Group.<br />
Hepatology 1999; 29: 889-896<br />
71 Chang TT, Lai CL, Chien RN, Guan R, Lim SG, Lee CM,<br />
Ng KY, Nicholls GJ, Dent JC, Leung NW. Four years <strong>of</strong><br />
lamivudine treatment in Chinese patients with chronic<br />
hepatitis B. J Gastroenterol Hepatol 2004; 19: 1276-1282<br />
72 Liaw YF, Chien RN, Yeh CT. No benefit to continue<br />
lamivudine therapy after emergence <strong>of</strong> YMDD mutations.<br />
Antivir Ther 2004; 9: 257-262<br />
73 Guan R, Lai CL, Liaw YF, Lim SG, Lee CM. Efficacy and<br />
safety <strong>of</strong> 5 years lamivudine treatment <strong>of</strong> Chinese patients<br />
with chronic hepatitis B. J Gastroenterol Hepatol 2001; 16 Suppl 1:<br />
A60-A61<br />
74 Hadziyannis SJ, Tassopoulos NC, Heathcote EJ, Chang TT,<br />
Kitis G, Rizzetto M, Marcellin P, Lim SG, Goodman Z, Ma<br />
J, Arterburn S, Xiong S, Currie G, Brosgart CL. Long-term<br />
therapy with adefovir dipivoxil for HBeAg-negative chronic<br />
hepatitis B. N Engl J Med 2005; 352: 2673-2681<br />
75 Colonno R, Rose R, Levine S, Baldick J, Pokornowski K, Plym<br />
M, Yu C, Mazzucco C, Fang J, Hsu M, Walsh A, Eggers B,<br />
Thiry A, Tenney D. Entecavir two year resistance update:<br />
no resistance observed in nucleotide naïve patients and low<br />
frequency resistance emergence in lamivudine refractory<br />
patients. Hepatology 2005; 42 Suppl 1: 573A<br />
76 Liaw YF, Leung NW, Chang TT, Guan R, Tai DI, Ng KY,<br />
Chien RN, Dent J, Roman L, Edmundson S, Lai CL. Effects<br />
<strong>of</strong> extended lamivudine therapy in Asian patients with<br />
chronic hepatitis B. Asia Hepatitis Lamivudine Study Group.<br />
<strong>Gastroenterology</strong> 2000; 119: 172-<strong>18</strong>0<br />
77 Marcellin P, Chang TT, Lim SG, Sievert W, Tong M, Arterburn<br />
S, Xiong S, Brosgart CL, Currie G. Increasing serologic,<br />
virologic and biochemical response over time to adefovir<br />
dipivoxil (ADV) 10 mg in HBeAg+ chronic hepatitis B (CHB)<br />
patients. J Hepatology 2005; 42 Suppl 2: 31-32<br />
78 Mao YM, Zheng MD, Yao GB, Xu DZ, Hou JL, Chen YG,<br />
Dixon JS, Barker KF. Efficacy and safety <strong>of</strong> two years therapy<br />
with adefovir dipixoxil (ADV) in Chinese subjects with HBeAg<br />
positive chronic hepatitis B (CHB). J Hepatology 2006; 44 Suppl 2:<br />
S<strong>18</strong>5<br />
79 Gish RG, Chang TT, de Man RA, Gadano A, Sollano J, Han<br />
KW, Lok A, Arbor A, Zhu J, Cross A, Brett-Smith H, Fernandes<br />
L. Entecavir results in sustantial virologic and biochemical<br />
improvement and HBeAg seroconversion through 96 weeks<br />
<strong>of</strong> treatment in HBeAg(+) chronic hepatitis B patients (study<br />
ETV-022). Hepatology 2005; 42 Suppl 1: 267A<br />
80 Colonno RJ, Rose RE, Baldick CJ, Levine SM, Klesczewski K,<br />
Tenney DJ. High barrier to resistance results in no emergence<br />
<strong>of</strong> entecavir resistance in nucleoside-naïve subjects during the<br />
first two years <strong>of</strong> therapy. J Hepatology 2006; 44 Suppl 2: S<strong>18</strong>2<br />
81 Dienstag JL, Cianciara J, Karayalcin S, Kowdley KV, Willems<br />
B, Plisek S, Woessner M, Gardner S, Schiff E. Durability <strong>of</strong><br />
serologic response after lamivudine treatment <strong>of</strong> chronic<br />
hepatitis B. Hepatology 2003; 37: 748-755<br />
82 Song BC, Suh DJ, Lee HC, Chung YH, Lee YS. Hepatitis B e<br />
antigen seroconversion after lamivudine therapy is not durable<br />
in patients with chronic hepatitis B in Korea. Hepatology 2000;<br />
32: 803-806<br />
83 Ryu SH, Chung YH, Choi MH, Kim JA, Shin JW, Jang MK,<br />
Park NH, Lee HC, Lee YS, Suh DJ. Long-term additional<br />
lamivudine therapy enhances durability <strong>of</strong> lamivudineinduced<br />
HBeAg loss: a prospective study. J Hepatol 2003; 39:<br />
614-619<br />
84 Chang TT, Schiffman ML, Tong M, Liaw YF, Komolmit P,
Leemans WF et al . Management <strong>of</strong> chronic HBV 2565<br />
Sorbel J, Arterburn S, Mondou E, Chuck S, Marcellini P.<br />
Durability <strong>of</strong> HBeAg seroconversion following adefovir<br />
dipivoxil treatment for chronic hepatitis B. J Hepatology 2006;<br />
44 Suppl 2: S<strong>18</strong>7<br />
85 Lee HW, Han K-W, Myoung SM, Chung YH, Park JY, Lee<br />
JH, Kim JK, Ahn SH, Paik YH, Lee KS, Chon CY, Moon YM.<br />
Virologic response can be durable in HBeAg positive patients<br />
with chronic hepatitis B after lamivudine monotherapy during<br />
long-term follow-up. Hepatology 2006; 44 Suppl 1: 516A-517A<br />
86 Gish RG, De MAn RA, Pedersen C, Bialkowska J, Chang<br />
TT, Apelian D, Zhu J, Cross A, Wilber R. Sustained response<br />
<strong>of</strong>f-treatment to entecavir and lamivudine after 48 weeks <strong>of</strong><br />
treatement in nucleoside-naïve, HBeAg(+) patients: 24-week<br />
follow-up results <strong>of</strong> phase 3 study ETV-022. J Hepatology 2005;<br />
42 Suppl 2: 177<br />
87 Fung SK, Wong F, Hussain M, Lok AS. Sustained response<br />
after a 2-year course <strong>of</strong> lamivudine treatment <strong>of</strong> hepatitis B<br />
e antigen-negative chronic hepatitis B. J Viral Hepat 2004; 11:<br />
432-438<br />
88 Sung JJ, Wong ML, Bowden S, Liew CT, Hui AY, Wong VW,<br />
Leung NW, Locarnini S, Chan HL. Intrahepatic hepatitis B<br />
virus covalently closed circular DNA can be a predictor <strong>of</strong><br />
sustained response to therapy. <strong>Gastroenterology</strong> 2005; 128:<br />
<strong>18</strong>90-<strong>18</strong>97<br />
89 Fukada M, Yatsuhashi H, Hamada R, Nakao R, Hai N,<br />
Miyazato M, Ozawa E, Kamihira T, Nagaoka S, Taura N,<br />
Ohata K, Abiru S, Yano K, Komori A, Daikoku M, Nakamura<br />
M, Migita K, Fujioka H, Ishabashi H. Hepatitis B virus corerelated<br />
antigen as an indicator <strong>of</strong> safe discontinuation <strong>of</strong><br />
lamivudine therapy. Hepatology 2006; 44 Suppl 1: 562A<br />
90 Huang ZM, Huang QW, Qin YQ, He YZ, Qin HJ, Zhou YN,<br />
Xu X, Huang MJ. YMDD mutations in patients with chronic<br />
hepatitis B untreated with antiviral medicines. <strong>World</strong> J<br />
Gastroenterol 2005; 11: 867-870<br />
91 Schildgen O, Sirma H, Funk A, Olotu C, Wend UC, Hartmann<br />
H, Helm M, Rockstroh JK, Willems WR, Will H, Gerlich<br />
WH. Variant <strong>of</strong> hepatitis B virus with primary resistance to<br />
adefovir. N Engl J Med 2006; 354: <strong>18</strong>07-<strong>18</strong>12<br />
92 Schildgen O, Hartmann H, Gerlich WH. Replacement <strong>of</strong><br />
ten<strong>of</strong>ovir with adefovir may result in reactivation <strong>of</strong> hepatitis<br />
B virus replication. Scand J Gastroenterol 2006; 41: 245-246<br />
93 van Bommel F, Zollner B, Sarrazin C, Spengler U, Huppe D,<br />
Moller B, Feucht HH, Wiedenmann B, Berg T. Ten<strong>of</strong>ovir for<br />
patients with lamivudine-resistant hepatitis B virus (HBV)<br />
infection and high HBV DNA level during adefovir therapy.<br />
Hepatology 2006; 44: 3<strong>18</strong>-325<br />
94 van Bommel F, Berg T. Reactivation <strong>of</strong> viral replication after<br />
replacement <strong>of</strong> ten<strong>of</strong>ovir by adefovir. Hepatology 2005; 42:<br />
239-240<br />
95 Delaney WE 4th, Yang H, Miller MD, Gibbs CS, Xiong S.<br />
Combinations <strong>of</strong> adefovir with nucleoside analogs produce<br />
additive antiviral effects against hepatitis B virus in vitro.<br />
Antimicrob Agents Chemother 2004; 48: 3702-3710<br />
96 Lau G, Cooksley H, Ribeiro RM, Bowden S, Mommeja-Marin<br />
H, Lewin S, Rousseau F, Perelson AS, Locarnini S, Naoumov<br />
NV. Randomized, double-blind study comparing adefovir<br />
dipivoxil (ADV) plus emtricitabine (FTC) combination therapy<br />
versus ADV alone in HBeAg(+) chronic hepatitis B: efficacy<br />
and mechanisms <strong>of</strong> treatment response. Hepatology 2004; 40<br />
Suppl 1: 272A<br />
97 Lucas JL, Carriero DC, Juriel A, Jaffe D, Dietrich DT. Effect <strong>of</strong><br />
switching to ten<strong>of</strong>ovir with either emtricitabine or lamivudine<br />
in patients with chronic hepatitis B failing to respond to an<br />
adefovir-containing regimen. Hepatology 2004; 40 Suppl 1:<br />
665A<br />
98 Lai CL, Dienstag J, Schiff E, Leung NW, Atkins M, Hunt C,<br />
Brown N, Woessner M, Boehme R, Condreay L. Prevalence<br />
and clinical correlates <strong>of</strong> YMDD variants during lamivudine<br />
therapy for patients with chronic hepatitis B. Clin Infect Dis<br />
2003; 36: 687-696<br />
99 Ide T, Kumashiro R, Koga Y, Tanaka E, Hino T, Hisamochi<br />
A, Murashima S, Ogata K, Tanaka K, Kuwahara R, Sata M. A<br />
real-time quantitative polymerase chain reaction method for<br />
hepatitis B virus in patients with chronic hepatitis B treated<br />
with lamivudine. Am J Gastroenterol 2003; 98: 2048-2051<br />
100 Yuen MF, Sablon E, Hui CK, Yuan HJ, Decraemer H, Lai CL.<br />
Factors associated with hepatitis B virus DNA breakthrough in<br />
patients receiving prolonged lamivudine therapy. Hepatology<br />
2001; 34: 785-791<br />
101 Fung SK, Chae HB, Fontana RJ, Conjeevaram H, Marrero J,<br />
Oberhelman K, Hussain M, Lok AS. Virologic response and<br />
resistance to adefovir in patients with chronic hepatitis B. J<br />
Hepatol 2006; 44: 283-290<br />
102 Lee YS, Suh DJ, Lim YS, Jung SW, Kim KM, Lee HC, Chung<br />
YH, Lee YS, Yoo W, Kim SO. Increased risk <strong>of</strong> adefovir<br />
resistance in patients with lamivudine-resistant chronic<br />
hepatitis B after 48 weeks <strong>of</strong> adefovir dipivoxil monotherapy.<br />
Hepatology 2006; 43: 1385-1391<br />
103 Locarnini S, Qi X, Arterburn S, Snow A, Brosgart C, Currie<br />
G, Wulfsohn M, Miller MD, Xiong S. Incidence and predictors<br />
<strong>of</strong> emergence <strong>of</strong> adefovir resistant HBV during four years <strong>of</strong><br />
adefovir dipivoxil (ADV) therapy for patients with chronic<br />
hepatitis B (CHB). J Hepatology 2005; 42 Suppl 2: 17<br />
104 Sun J, Wang Z, Ma S, Zeng G, Zhou Z, Luo K, Hou J. Clinical<br />
and virological characteristics <strong>of</strong> lamivudine resistance in<br />
chronic hepatitis B patients: a single center experience. J Med<br />
Virol 2005; 75: 391-398<br />
105 Moskovitz DN, Osiowy C, Giles E, Tomlinson G, Heathcote<br />
EJ. Response to long-term lamivudine treatment (up to 5<br />
years) in patients with severe chronic hepatitis B, role <strong>of</strong><br />
genotype and drug resistance. J Viral Hepat 2005; 12: 398-404<br />
106 Yuen MF, Tanaka Y, Lai CL. Hepatitis B genotypes in chronic<br />
hepatitis B and lamivudine therapy. Intervirology 2003; 46:<br />
373-376<br />
107 Yuen MF, Wong DK, Sablon E, Yuan HJ, Sum SM, Hui CK,<br />
Chan AO, Wang BC, Lai CL. Hepatitis B virus genotypes<br />
B and C do not affect the antiviral response to lamivudine.<br />
Antivir Ther 2003; 8: 531-534<br />
108 Suzuki F, Tsubota A, Arase Y, Suzuki Y, Akuta N, Hosaka<br />
T, Someya T, Kobayashi M, Saitoh S, Ikeda K, Kobayashi<br />
M, Matsuda M, Satoh J, Takagi K, Kumada H. Efficacy <strong>of</strong><br />
lamivudine therapy and factors associated with emergence<br />
<strong>of</strong> resistance in chronic hepatitis B virus infection in Japan.<br />
Intervirology 2003; 46: <strong>18</strong>2-<strong>18</strong>9<br />
109 Orito E, Fujiwara K, Tanaka Y, Yuen MF, Lai CL, Kato T,<br />
Sugauchi F, Kusakabe A, Sata M, Okanoue T, Niitsuma H,<br />
Sakugawa H, Hasegawa I, Mizokami M. A case-control study<br />
<strong>of</strong> response to lamivudine therapy for 2 years in Japanese and<br />
Chinese patients chronically infected with hepatitis B virus <strong>of</strong><br />
genotypes Bj, Ba and C. Hepatol Res 2006; 35: 127-134<br />
110 Akuta N, Suzuki F, Kobayashi M, Tsubota A, Suzuki Y,<br />
Hosaka T, Someya T, Kobayashi M, Saitoh S, Arase Y, Ikeda<br />
K, Kumada H. The influence <strong>of</strong> hepatitis B virus genotype on<br />
the development <strong>of</strong> lamivudine resistance during long-term<br />
treatment. J Hepatol 2003; 38: 315-321<br />
111 Zollner B, Petersen J, Schroter M, Laufs R, Schoder V, Feucht<br />
HH. 20-fold increase in risk <strong>of</strong> lamivudine resistance in<br />
hepatitis B virus subtype adw. Lancet 2001; 357: 934-935<br />
112 Zollner B, Petersen J, Puchhammer-Stockl E, Kletzmayr J,<br />
Sterneck M, Fischer L, Schroter M, Laufs R, Feucht HH. Viral<br />
features <strong>of</strong> lamivudine resistant hepatitis B genotypes A and D.<br />
Hepatology 2004; 39: 42-50<br />
113 Locarnini S, Hatzakis A, Heathcote J, Keeffe EB, Liang TJ,<br />
Mutimer D, Pawlotsky JM, Zoulim F. Management <strong>of</strong> antiviral<br />
resistance in patients with chronic hepatitis B. Antivir Ther<br />
2004; 9: 679-693<br />
114 Lok AS, McMahon BJ. AASLD Practice Guidelines.<br />
Chronic hepatitis B: update <strong>of</strong> therapeutic guidelines. Rom J<br />
Gastroenterol 2004; 13: 150-154<br />
115 Lok AS, McMahon BJ. Chronic hepatitis B: update <strong>of</strong><br />
recommendations. Hepatology 2004; 39: 857-861<br />
116 Papatheodoridis GV, Dimou E, Laras A, Papadimitropoulos<br />
V, Hadziyannis SJ. Course <strong>of</strong> virologic breakthroughs under<br />
long-term lamivudine in HBeAg-negative precore mutant<br />
HBV liver disease. Hepatology 2002; 36: 219-226<br />
117 Durantel D, Brunelle MN, Gros E, Carrouee-Durantel S,<br />
www.wjgnet.com
2566 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Pichoud C, Villet S, Trepo C, Zoulim F. Resistance <strong>of</strong> human<br />
hepatitis B virus to reverse transcriptase inhibitors: from<br />
genotypic to phenotypic testing. J Clin Virol 2005; 34 Suppl 1:<br />
S34-S43<br />
1<strong>18</strong> Peters MG, Hann Hw H, Martin P, Heathcote EJ, Buggisch<br />
P, Rubin R, Bourliere M, Kowdley K, Trepo C, Gray Df D,<br />
Sullivan M, Kleber K, Ebrahimi R, Xiong S, Brosgart CL.<br />
Adefovir dipivoxil alone or in combination with lamivudine<br />
in patients with lamivudine-resistant chronic hepatitis B.<br />
<strong>Gastroenterology</strong> 2004; 126: 91-101<br />
119 Manolakopoulos S, Bethanis S, Koutsounas S, Goulis<br />
J, Saverriadis A, Xristias E, Christidou A, Pavlidis C,<br />
Toubanakis C, Vlachogiannakos J, Triantos C, Avgerionos<br />
A, Tzourmakliotis D. Adefovir alone or combination with<br />
lamivudine in patients with lamivudine-resistance chronic<br />
HBeAg-negative heptitis B. A non randomized multicenter<br />
controlled trial. Hepatology 2005; 42 Suppl 2: 592A-593A<br />
120 Barbon V, Marzano A, Carenzi S, Lagget M, Aleesandria C,<br />
Olivero A, Gaia S, Ciancio A, Smedile A, Rizetto M. Treatment<br />
with adefovir alone or in combination with lamivudine in<br />
chronic hepatitis B lamivudine resistant patients: results after<br />
two years. J Hepatology 2006; 44 Suppl 2: S178-S179<br />
121 Lada O, Benhamou Y, Cahour A, Katlama C, Poynard T,<br />
Thibault V. In vitro susceptibility <strong>of</strong> lamivudine-resistant<br />
hepatitis B virus to adefovir and ten<strong>of</strong>ovir. Antivir Ther 2004; 9:<br />
353-363<br />
122 Ono SK, Kato N, Shiratori Y, Kato J, Goto T, Schinazi RF,<br />
Carrilho FJ, Omata M. The polymerase L528M mutation<br />
cooperates with nucleotide binding-site mutations, increasing<br />
hepatitis B virus replication and drug resistance. J Clin Invest<br />
2001; 107: 449-455<br />
123 Yang H, Qi X, Sabogal A, Miller M, Xiong S, Delaney WE<br />
4th. Cross-resistance testing <strong>of</strong> next-generation nucleoside<br />
and nucleotide analogues against lamivudine-resistant HBV.<br />
Antivir Ther 2005; 10: 625-633<br />
124 Zeng M, Mao Y, Yao G, Wang H, Hou J, Wang Y, Ji BN, Chang<br />
CN, Barker KF. A double-blind randomized trial <strong>of</strong> adefovir<br />
dipivoxil in Chinese subjects with HBeAg-positive chronic<br />
hepatitis B. Hepatology 2006; 44: 108-116<br />
125 Lee Y, Chung Y, Ryu SH, Kim JA, Choi MH, Jung SW, Kim<br />
SH, Shin JW, Kim KM, Lim YS, Lee YS. Hepatitis B virus with<br />
rtL80V/I mutation associates with poor response to adefovir<br />
dipivoxil therapy. Hepatology 2005; 42 Suppl 1: 575A<br />
126 Liu CJ, Kao JH, Chen PJ, Chen TC, Lin FY, Lai MY, Chen<br />
DS. Overlap lamivudine treatment in patients with chronic<br />
hepatitis B receiving adefovir for lamivudine-resistant viral<br />
mutants. J Viral Hepat 2006; 13: 387-395<br />
127 Tenney DJ, Levine SM, Rose RE, Walsh AW, Weinheimer<br />
SP, Discotto L, Plym M, Pokornowski K, Yu CF, Angus P,<br />
Ayres A, Bartholomeusz A, Sievert W, Thompson G, Warner<br />
N, Locarnini S, Colonno RJ. Clinical emergence <strong>of</strong> entecavirresistant<br />
hepatitis B virus requires additional substitutions<br />
in virus already resistant to Lamivudine. Antimicrob Agents<br />
Chemother 2004; 48: 3498-3507<br />
128 Levine S, Hernandez D, Yamanaka G, Zhang S, Rose R,<br />
Weinheimer S, Colonno RJ. Efficacies <strong>of</strong> entecavir against<br />
lamivudine-resistant hepatitis B virus replication and<br />
recombinant polymerases in vitro. Antimicrob Agents Chemother<br />
2002; 46: 2525-2532<br />
129 Sherman M, Yurdaydin C, Sollano J, Silva M, Liaw YF,<br />
Cianciara J, Boron-Kaczmarska A, Martin P, Goodman Z,<br />
Colonno R, Cross A, Denisky G, Kreter B, Hindes R. Entecavir<br />
for treatment <strong>of</strong> lamivudine-refractory, HBeAg-positive<br />
chronic hepatitis B. <strong>Gastroenterology</strong> 2006; 130: 2039-2049<br />
130 Colonno RJ, Rose RE, Pokornowski K, Baldick CJ, Klesczewski<br />
K, Tenney D. Assessment at three years shows high barrier to<br />
resistance is maintained in entecavir-treated nucleoside naïve<br />
patients while resistance emergence increases over time in<br />
lamivudine refractory patients. Hepatology 2006; 44 Suppl 1:<br />
229A-230A<br />
131 de Vries-Sluijs TE, van der Eijk AA, Hansen BE, Osterhaus<br />
AD, de Man RA, van der Ende ME. Wild type and YMDD<br />
variant <strong>of</strong> hepatitis B virus: no difference in viral kinetics<br />
www.wjgnet.com<br />
on lamivudine/ten<strong>of</strong>ovir therapy in HIV-HBV co-infected<br />
patients. J Clin Virol 2006; 36: 60-63<br />
132 Hann HW, Chae HB, Dunn SR. Ten<strong>of</strong>ovir (TNV) has<br />
stronger antiviral effect than adefovir dipivoxil (ADV)<br />
against lamivudine (LAM) resistant hepatitis B virus (HBV). J<br />
Hepatology 2006; 44 Suppl 2: S<strong>18</strong>4-S<strong>18</strong>5<br />
133 Sheldon J, Camino N, Rodes B, Bartholomeusz A, Kuiper M,<br />
Tacke F, Nunez M, Mauss S, Lutz T, Klausen G, Locarnini S,<br />
Soriano V. Selection <strong>of</strong> hepatitis B virus polymerase mutations<br />
in HIV-coinfected patients treated with ten<strong>of</strong>ovir. Antivir Ther<br />
2005; 10: 727-734<br />
134 Mauss S, Nelson M, Lutz T, Sheldon J, Bruno R, Bömmel vF,<br />
Rockstroh JK, Wolf E, Stoehr A, Soriano V, Berger F, Berg<br />
T, Carlebach A, Schwarze-Zander C, Wunsche T, Jaeger H,<br />
Schmutz G. First line combination therapy <strong>of</strong> chronic hepatitis<br />
B with ten<strong>of</strong>ovir plus lamivudine versus sequential therapy<br />
with ten<strong>of</strong>ovir therapy after lamivudine failure. Hepatology<br />
2005; 42 Suppl 1: 574A-575A<br />
135 Brunelle MN, Jacquard AC, Pichoud C, Durantel D, Carrouee-<br />
Durantel S, Villeneuve JP, Trepo C, Zoulim F. Susceptibility to<br />
antivirals <strong>of</strong> a human HBV strain with mutations conferring<br />
resistance to both lamivudine and adefovir. Hepatology 2005;<br />
41: 1391-1398<br />
136 Angus P, Vaughan R, Xiong S, Yang H, Delaney W, Gibbs C,<br />
Brosgart C, Colledge D, Edwards R, Ayres A, Bartholomeusz<br />
A, Locarnini S. Resistance to adefovir dipivoxil therapy<br />
associated with the selection <strong>of</strong> a novel mutation in the HBV<br />
polymerase. <strong>Gastroenterology</strong> 2003; 125: 292-297<br />
137 Fung SK, Andreone P, Han SH, Rajender Reddy K, Regev A,<br />
Keeffe EB, Hussain M, Cursaro C, Richtmyer P, Marrero JA,<br />
Lok AS. Adefovir-resistant hepatitis B can be associated with<br />
viral rebound and hepatic decompensation. J Hepatol 2005; 43:<br />
937-943<br />
138 Delaney WE 4th, Ray AS, Yang H, Qi X, Xiong S, Zhu Y, Miller<br />
MD. Intracellular metabolism and in vitro activity <strong>of</strong> ten<strong>of</strong>ovir<br />
against hepatitis B virus. Antimicrob Agents Chemother 2006; 50:<br />
2471-2477<br />
139 Villeneuve J, Willems B, Zoulim F. Efficacy <strong>of</strong> ten<strong>of</strong>ovir in<br />
patients with chronic hepatitis B and resistance or sub-optimal<br />
response to adefovir. Hepatology 2005; 42 Suppl 1: 588A<br />
140 Villet V, Pichoud C, Ollivet A, Villeneuve J, Trepo C, Zoulim F.<br />
Sequential antiviral therapy leads to the emergence <strong>of</strong> multiple<br />
drug resistant hepatitis B virus. Hepatology 2005; 42 Suppl 1:<br />
581A<br />
141 Marshall E. A shadow falls on hepatitis B vaccination effort.<br />
Science 1998; 281: 630-631<br />
142 Ascherio A, Zhang SM, Hernan MA, Olek MJ, Coplan PM,<br />
Brodovicz K, Walker AM. Hepatitis B vaccination and the risk<br />
<strong>of</strong> multiple sclerosis. N Engl J Med 2001; 344: 327-332<br />
143 Confavreux C, Suissa S, Saddier P, Bourdes V, Vukusic S.<br />
Vaccinations and the risk <strong>of</strong> relapse in multiple sclerosis.<br />
Vaccines in Multiple Sclerosis Study Group. N Engl J Med<br />
2001; 344: 319-326<br />
144 Jefferson T, Demicheli V. No evidence that vaccines cause<br />
insulin dependent diabetes mellitus. J Epidemiol Community<br />
Health 1998; 52: 674-675<br />
145 Lok AS, Wu PC, Lai CL, Lau JY, Leung EK, Wong LS, Ma OC,<br />
Lauder IJ, Ng CP, Chung HT. A controlled trial <strong>of</strong> interferon<br />
with or without prednisone priming for chronic hepatitis B.<br />
<strong>Gastroenterology</strong> 1992; 102: 2091-2097<br />
146 Brook MG, Karayiannis P, Thomas HC. Which patients with<br />
chronic hepatitis B virus infection will respond to alphainterferon<br />
therapy? A statistical analysis <strong>of</strong> predictive factors.<br />
Hepatology 1989; 10: 761-763<br />
147 Hui CK, Lai LS, Lam P, Zhang HY, Fung TT, Lai ST, Wong<br />
WM, Lo CM, Fan ST, Leung N, Lau GK. 48 weeks pegylated<br />
interferon alpha-2a is superior to 24 weeks <strong>of</strong> pegylated<br />
interferon alpha-2b in achieving hepatitis B e antigen<br />
seroconversion in chronic hepatitis B infection. Aliment<br />
Pharmacol Ther 2006; 23: 1171-1178<br />
148 Perrillo RP, Lai CL, Liaw YF, Dienstag JL, Schiff ER, Schalm<br />
SW, Heathcote EJ, Brown NA, Atkins M, Woessner M,<br />
Gardner SD. Predictors <strong>of</strong> HBeAg loss after lamivudine
Leemans WF et al . Management <strong>of</strong> chronic HBV 2567<br />
treatment for chronic hepatitis B. Hepatology 2002; 36: <strong>18</strong>6-194<br />
149 Chien RN, Liaw YF, Atkins M. Pretherapy alanine<br />
transaminase level as a determinant for hepatitis B e antigen<br />
seroconversion during lamivudine therapy in patients with<br />
chronic hepatitis B. Asian Hepatitis Lamivudine Trial Group.<br />
Hepatology 1999; 30: 770-774<br />
150 Alexander G, Baba CS, Chetri K, Negi TS, Choudhuri G. High<br />
rates <strong>of</strong> early HBeAg seroconversion and relapse in Indian<br />
patients <strong>of</strong> chronic hepatitis B treated with Lamivudine:<br />
results <strong>of</strong> an open labeled trial. BMC Gastroenterol 2005; 5: 29<br />
151 Chan HL, Leung NW, Hui AY, Wong VW, Liew CT, Chim<br />
AM, Chan FK, Hung LC, Lee YT, Tam JS, Lam CW, Sung JJ.<br />
A randomized, controlled trial <strong>of</strong> combination therapy for<br />
chronic hepatitis B: comparing pegylated interferon-alpha2b<br />
and lamivudine with lamivudine alone. Ann Intern Med 2005;<br />
142: 240-250<br />
152 Yao GB, Cui ZY, Wang BE, Yao JL, Zeng MD. A 3-year clinical<br />
trial <strong>of</strong> lamivudine in treatment <strong>of</strong> patients with chronic<br />
hepatitis B. Hepatobiliary Pancreat Dis Int 2004; 3: <strong>18</strong>8-193<br />
153 Jonas MM, Mizerski J, Badia IB, Areias JA, Schwarz KB, Little<br />
NR, Greensmith MJ, Gardner SD, Bell MS, Sokal EM. Clinical<br />
trial <strong>of</strong> lamivudine in children with chronic hepatitis B. N Engl<br />
J Med 2002; 346: 1706-1713<br />
154 Mazur W, Krol F, Cianciara J, Nazzal K, Gladysz A, Juszczyk<br />
J, Bolewska B, Adamek J, Czajka B, Swietek K, Kryczka W,<br />
Gonciarz Z. A multi-center open study to determine the effect<br />
<strong>of</strong> lamivudine on HBV DNA clearance and to assess the safety<br />
<strong>of</strong> the regimen in patients with chronic hepatitis B infection.<br />
Med Sci Monit 2002; 8: CR257-CR262<br />
155 Barbaro G, Zechini F, Pellicelli AM, Francavilla R, Scotto G,<br />
Bacca D, Bruno M, Babudieri S, Annese M, Matarazzo F, Di<br />
Stefano G, Barbarini G. Long-term efficacy <strong>of</strong> interferon alpha-<br />
2b and lamivudine in combination compared to lamivudine<br />
monotherapy in patients with chronic hepatitis B. An Italian<br />
multicenter, randomized trial. J Hepatol 2001; 35: 406-411<br />
156 Ooga H, Suzuki F, Tsubota A, Arase Y, Suzuki Y, Akuta N,<br />
Sezaki H, Hosaka T, Someya T, Kobayashi M, Saitoh S, Ikeda<br />
K, Kobayashi M, Matsuda M, Satoh J, Kumada H. Efficacy <strong>of</strong><br />
lamivudine treatment in Japanese patients with hepatitis B<br />
virus-related cirrhosis. J Gastroenterol 2004; 39: 1078-1084<br />
157 Janssen HL, Schalm SW, Berk L, de Man RA, Heijtink RA.<br />
Repeated courses <strong>of</strong> alpha-interferon for treatment <strong>of</strong> chronic<br />
hepatitis type B. J Hepatol 1993; 17 Suppl 3: S47-S51<br />
158 Carreno V, Marcellin P, Hadziyannis S, Salmeron J, Diago<br />
M, Kitis GE, Vafiadis I, Schalm SW, Zahm F, Manzarbeitia<br />
F, Jimenez FJ, Quiroga JA. Retreatment <strong>of</strong> chronic hepatitis<br />
B e antigen-positive patients with recombinant interferon<br />
alfa-2a. The European Concerted Action on Viral Hepatitis<br />
(EUROHEP). Hepatology 1999; 30: 277-282<br />
159 Munoz R, Castellano G, Fernandez I, Alvarez MV, Manzano<br />
ML, Marcos MS, Cuenca B, Solis-Herruzo JA. A pilot study <strong>of</strong><br />
beta-interferon for treatment <strong>of</strong> patients with chronic hepatitis<br />
B who failed to respond to alpha-interferon. J Hepatol 2002; 37:<br />
655-659<br />
160 Ballauff A, Schneider T, Gerner P, Habermehl P, Behrens<br />
R, Wirth S. Safety and efficacy <strong>of</strong> interferon retreatment in<br />
children with chronic hepatitis B. Eur J Pediatr 1998; 157:<br />
382-385<br />
161 Teuber G, Dienes HP, Meyer zum Buschenfelde KH, Gerken G.<br />
Re-treatment with interferon-alpha in chronic hepatitis B and<br />
C virus infection. Z Gastroenterol 1995; 33: 94-98<br />
162 Flink HJ, Hansen BE, Zonneveld M, Schalm SW, Janssen HL.<br />
Succesful treatment with pegylated interferon in HBV nonresponders<br />
to standard interferon and lamivudine. Hepatology<br />
2004; 40 Suppl 1: 663A-664A<br />
163 Lau GK, Piratvisuth T, Luo K-X, Marcellin P, Thongsawat<br />
S, Gane E, Fried MW, Cooksley G, Button P, Liaw YF. PEGinterferon<br />
α-2a (40 kDa) (Pegasys®) versus PEG-interferon<br />
α-2a plus lamivudine in HBeAg-positive chronic HBV: effect<br />
<strong>of</strong> <strong>of</strong> previous treatment and drug exposure on sustained<br />
response. J Hepatology 2005; 42 Suppl 2: 15<br />
164 Marcellin P, Boyer N, Piratvisuth T, Tanwandee T, Pooi<br />
Huat R, Gadano A, Mercado R, Pridadi F, Zhang HY, Wu Y.<br />
Efficacy and safety <strong>of</strong> peginterferon alpha-2a (40kD) (Pegasys)<br />
in patients with chronic hepatitis B who had received prior<br />
treatment with nucleos(t)ide analugues - the pegalam cohort. J<br />
Hepatology 2006; 44 Supp 2: S<strong>18</strong>7<br />
165 Buti M, Esteban R, Escartin P, Calleja JL, Enriquez J, Pons F,<br />
Crespo J, Bengoechea MG, Prieto M, Casanova T, Samaniego<br />
JG, Miras M, Roldan FP, Pelaez M, Frage E, Moreira V, Carro<br />
PG, Alonso G, Barcena R, Buey LG, Moreno R, Oliveira A,<br />
Mas A, Rueda M. Continued efficacy and safety <strong>of</strong> adefovir<br />
dipivoxil in chronic hepatitis B patients with lamivudine<br />
resistant HBV: 1 year results. Hepatology 2004; 40 Suppl 1:<br />
671A<br />
166 Koskinas J, Manesis EK, Kountouras D, Papaioannou CH,<br />
Pantazis K, Agelopoulou O, Archimandritis A. Adefovir<br />
dipivoxil alone or in combination with lamivudine in HBeAg<br />
negative patients with lamivudine resistant chronic hepatitis B:<br />
a prospective, randomized study. J Hepatology 2005; 42 Suppl 2:<br />
S<strong>18</strong>1<br />
167 Lampertico P, Vigano M, Manenti E, Iavarone M, Lunghi<br />
G, Colombo M. Adefovir rapidly suppresses hepatitis B in<br />
HBeAg-negative patients developing genotypic resistance to<br />
lamivudine. Hepatology 2005; 42: 1414-1419<br />
168 Vassiliadis T, Nikolaidis N, Giouleme O, Tziomalos<br />
K, Grammatikos N, Patsiaoura K, Zezos P, Gkisakis D,<br />
Theodoropoulos K, Katsinelos P, Orfanou-Koumerkeridou E,<br />
Eugenidis N. Adefovir dipivoxil added to ongoing lamivudine<br />
therapy in patients with lamivudine-resistant hepatitis B e<br />
antigen-negative chronic hepatitis B. Aliment Pharmacol Ther<br />
2005; 21: 531-537<br />
169 Moriconi F, Flinchman D, Ciccorossi P, Coco B, Sacco R,<br />
Oliveri F, Colombatto P, Bonino F, Brunetto MR. HBV<br />
Quasispecies selected during lamivudine treatment may<br />
contribute to adefovir dipivoxil resistance. J Hepatology 2006;<br />
44 Suppl 2: S<strong>18</strong>8<br />
170 Chang TT, Gish RG, Hadziyannis SJ, Cianciara J, Rizzetto<br />
M, Schiff ER, Pastore G, Bacon BR, Poynard T, Joshi S,<br />
Klesczewski KS, Thiry A, Rose RE, Colonno RJ, Hindes RG. A<br />
dose-ranging study <strong>of</strong> the efficacy and tolerability <strong>of</strong> entecavir<br />
in Lamivudine-refractory chronic hepatitis B patients.<br />
<strong>Gastroenterology</strong> 2005; 129: 1198-1209<br />
171 Karino Y, Toyota J, Kumada H, Katano Y, Izumi N, Shiratori<br />
Y, Sata M, Seriu T, Omata M. Efficacy and safety <strong>of</strong> entecavir<br />
in Japanese adult patients with incomplete response to current<br />
lamivudine treatment: a phaseII clinical trial. J Hepatol 2006; 44<br />
Suppl 2: S<strong>18</strong>5-S<strong>18</strong>6<br />
172 Yao G, Zhou X, Xu D, Wang BC, Ren H, Jiang M, Liu J, Xu D,<br />
MacDonald L. Entecavir results in early viral load reduction<br />
in chronic hepatitis B patients who have failed lamivudine<br />
therapy: a randomized placebo-controlled trial. J Hepatol 2006;<br />
44 Suppl 2: S193<br />
173 van der Eijk AA, Hansen BE, Niesters HG, Janssen HL, van<br />
de Ende M, Schalm SW, de Man RA. Viral dynamics during<br />
ten<strong>of</strong>ovir therapy in patients infected with lamivudineresistant<br />
hepatitis B virus mutants. J Viral Hepat 2005; 12:<br />
364-372<br />
174 Dore GJ, Cooper DA, Pozniak AL, DeJesus E, Zhong L,<br />
Miller MD, Lu B, Cheng AK. Efficacy <strong>of</strong> ten<strong>of</strong>ovir disoproxil<br />
fumarate in antiretroviral therapy-naive and -experienced<br />
patients coinfected with HIV-1 and hepatitis B virus. J Infect<br />
Dis 2004; <strong>18</strong>9: 1<strong>18</strong>5-1192<br />
175 Nunez M, Perez-Olmeda M, Diaz B, Rios P, Gonzalez-Lahoz J,<br />
Soriano V. Activity <strong>of</strong> ten<strong>of</strong>ovir on hepatitis B virus replication<br />
in HIV-co-infected patients failing or partially responding to<br />
lamivudine. AIDS 2002; 16: 2352-2354<br />
176 Nelson M, Portsmouth S, Stebbing J, Atkins M, Barr A,<br />
Matthews G, Pillay D, Fisher M, Bower M, Gazzard B. An<br />
open-label study <strong>of</strong> ten<strong>of</strong>ovir in HIV-1 and Hepatitis B virus<br />
co-infected individuals. AIDS 2003; 17: F7-F10<br />
177 Benhamou Y, Tubiana R, Thibault V. Ten<strong>of</strong>ovir disoproxil<br />
fumarate in patients with HIV and lamivudine-resistant<br />
hepatitis B virus. N Engl J Med 2003; 348: 177-178<br />
S- Editor Zhu LH L- Editor Karam SM E- Editor Chen GJ<br />
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GASTRIC CANCER<br />
Promoter hypermethylation <strong>of</strong> CDH1 , FHIT , MTAP and PLAGL1<br />
in gastric adenocarcinoma in individuals from Northern Brazil<br />
Mariana Ferreira Leal, Eleonidas Moura Lima, Patrícia Natália Oliveira Silva, Paulo Pimentel Assumpção,<br />
Danielle Queiroz Calcagno, Spencer Luiz Marques Payão, Rommel Rodríguez Burbano,<br />
Marília de Arruda Cardoso Smith<br />
Mariana Ferreira Leal, Patrícia Natália Oliveira Silva, Marília<br />
de Arruda Cardoso Smith, Genetics Division, Department <strong>of</strong><br />
Morphology, Federal University <strong>of</strong> São Paulo, São Paulo, SP,<br />
Brazil<br />
Eleonidas Moura Lima, Department <strong>of</strong> Biology, Campus<br />
Ministro Reis Velloso/Parnába, Federal University <strong>of</strong> Piauí, PI,<br />
Brazil<br />
Danielle Queiroz Calcagno, Rommel Rodríguez Burbano,<br />
Human Cytogenetics and Toxicological Genetics Laboratory,<br />
Department <strong>of</strong> Biology, Center <strong>of</strong> Biological Sciences, Federal<br />
University <strong>of</strong> Pará, Belém, PA, Brazil<br />
Paulo Pimentel Assumpção, João de Barros Barreto University<br />
Hospital, Federal University <strong>of</strong> Pará, Belém, PA, Brazil<br />
Spencer Luiz Marques Payão, Genetics and Molecular Biology,<br />
Hemocenter, Faculty <strong>of</strong> Medicine <strong>of</strong> Marília, Marília, SP, Brazil<br />
Supported by Fundação de Amparo à Pesquisa do Estado de<br />
São Paulo, Coordenação de Aperfeiçoamento de Pessoal de Nível<br />
Superior and Conselho Nacional de Desenvolvimento Científico e<br />
Tecnológico<br />
Correspondence to: Marília de Arruda Cardoso Smith, Disciplina<br />
de Genética, Departamento de Morfologia, Universidade Federal de<br />
São Paulo/Escola Paulista de Medicina, Rua Botucatu 740, Edifício<br />
Leitão da Cunha, 1º andar, CEP: 04023-900, São Paulo, SP,<br />
Brazil. macsmith.morf@epm.br<br />
Telephone: +55-11-55764260 Fax: +55-11-55764260<br />
Received: 2007-01-23 Accepted: 2007-02-08<br />
Abstract<br />
AIM: To evaluate the methylation status o�� o�� CDH1, FHIT,<br />
MTAP and PLAGL1 promoters and the association o��<br />
these findings with clinico-pathological characteristics.<br />
METHODS: Methylation-specific PCR (MSP) assay was<br />
per��ormed in 13 nonneoplastic gastric adenocarcinoma,<br />
30 intestinal-type gastric adenocarcinoma and 35 diffusetype<br />
gastric adenocarcinoma samples ��rom individuals<br />
in Northern Brazil. Statistical analyses were performed<br />
using the chi-square or Fisher’s exact test to assess<br />
associations between methylation status and clinicopathological<br />
characteristics.<br />
RESULTS: Hypermethylation ��requencies o�� CDH1, FHIT,<br />
MTAP and PLAGL1 promoter were 98.7%, 53.9%, 23.1%<br />
and 29.5%, respectively. Hypermethylation <strong>of</strong> three<br />
or four genes revealed a significant association with<br />
diffuse-type gastric cancer compared with nonneoplastic<br />
cancer. A higher hypermethylation frequency was<br />
www.wjgnet.com<br />
significantly associated with H pylori in��ection in gastric<br />
cancers, especially with diffuse-type. Cancer samples<br />
without lymph node metastasis showed a higher FHIT<br />
hypermethylation frequency. MTAP hypermethylation was<br />
associated with H pylori in gastric cancer samples, as<br />
well as with diffuse-type compared with intestinal-type.<br />
In diffuse-type, MTAP hypermethylation was associated<br />
with female gender.<br />
CONCLUSION: Our findings show differential gene<br />
methylation in tumoral tissue, which allows us to<br />
conclude that hypermethylation is associated with gastric<br />
carcinogenesis. MTAP promoter hypermethylation can<br />
be characterized as a marker <strong>of</strong> diffuse-type gastric<br />
cancer, especially in women and may help in diagnosis,<br />
prognosis and therapies. The H pylori in��ectious agent<br />
was present in 44.9% <strong>of</strong> the samples. This infection<br />
may be correlated with the carcinogenic process<br />
through the gene promoter hypermethylation, especially<br />
the MTAP promoter in diffuse-type. A higher H pylori<br />
infection in diffuse-type may be due to greater genetic<br />
predisposition.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Gastric adenocarcinoma; DNA hypermethylation;<br />
CDH1; FHIT; MTAP; PLAGL1<br />
Leal MF, Lima EM, Silva PNO, Assumpção PP, Calcagno<br />
DQ, Payão SLM, Burbano RR, de Arruda Cardoso Smith<br />
M. Promoter hypermethylation <strong>of</strong> CDH1, FHIT, MTAP and<br />
PLAGL1 in gastric adenocarcinoma in individuals ��rom<br />
Northern Brazil. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>):<br />
2568-2574<br />
http://www.wjgnet.com/1007-9327/13/2568.asp<br />
INTRODUCTION<br />
Gastric cancer (GC) is the most frequent type <strong>of</strong> cancer<br />
and is the second most common cause <strong>of</strong> cancer death<br />
in the world [1] . In Northern Brazil, the State <strong>of</strong> Pará has<br />
a high incidence <strong>of</strong> this neoplasia and its capital, Belém,<br />
is ranked eleventh in terms <strong>of</strong> GC incidence rates among<br />
all cities in the world with cancer records [2] . Food may be<br />
related to the high incidence <strong>of</strong> this neoplasia in Pará,
Leal MF et al . Promoter hypermethylation in gastric cancer 2569<br />
especially the high consumption <strong>of</strong> salt-conserved food,<br />
reduced use <strong>of</strong> refrigerators and little consumption <strong>of</strong><br />
fresh fruit and vegetables [3] .<br />
The most successful and widely used classification<br />
<strong>of</strong> GC is that <strong>of</strong> Laurén [4] , which is divided in two main<br />
types: diffuse and intestinal. Intestinal-type GC is usually<br />
called “epidemic”, is more frequent, more related to<br />
environmental factors and associated with precancerous<br />
lesions, such as chronic gastritis, gastric atrophy, intestinal<br />
metaplasia and dysplasia. Diffuse-type have a poorer<br />
prognosis, are not associated with precancerous lesions<br />
and show invasive growth patterns [5] .<br />
Epigenetic events play a significant role in cancer<br />
development and progression. DNA methylation is the<br />
most studied epigenetic alteration, occurring through<br />
the addition <strong>of</strong> a methyl radical to the cytosine base<br />
adjacent to guanine. When DNA is methylated in the gene<br />
promoter region, genes are inactivated and silenced [6] . In<br />
cancer, epigenetic silencing leads to the aberrant silencing<br />
<strong>of</strong> normal tumor-suppressor functions.<br />
Four genes were chosen for assessment <strong>of</strong> their<br />
functions and/or roles in gastric carcinogenesis: CDH1,<br />
FHIT, MTAP and PLAGL1.<br />
E-cadherin, CDH1 product, is a homophilic cell<br />
adhesion protein. It has been proposed that loss <strong>of</strong><br />
E-cadherin-mediated cell-cell adhesion is a prerequisite for<br />
tumor cell invasion and metastasis [7] . E-cadherin also has<br />
a possible role in modulating intracellular signaling, thus<br />
promoting tumor growth [8] .<br />
FHIT gene was identified in the most common fragile<br />
site, FRA3B [9] . FHIT is highly expressed in all normal<br />
epithelial tissues. FHIT is inactivated in about 60% <strong>of</strong><br />
human tumors (ranging from 20% to 100%). Thus, FHIT<br />
is the most commonly altered gene in human cancer and<br />
in precancerous conditions [10] . Despite strong evidence<br />
<strong>of</strong> a FHIT tumor suppressor function, the specific signal<br />
pathways and mechanisms involved are still unknown.<br />
MTAP is expressed ubiquitously in all normal cells [11] .<br />
Reduced MTAP expression may lead to activation <strong>of</strong> the<br />
polyamine biosynthetic enzyme ornithine decarboxylase<br />
(ODC) [12] . In gastric tissue, the ODC activity is elevated in<br />
premalignant lesions, which may be useful as biochemical<br />
markers <strong>of</strong> neoplastic proliferation [13] . Many malignant<br />
cells lack MTAP activity because <strong>of</strong> chromosomal loss or<br />
epigenetic regulation [14] . To our knowledge, the methylation<br />
status <strong>of</strong> MTAP has not been reported in GC.<br />
PLAGL1 encodes a zinc-finger protein that regulate<br />
induction <strong>of</strong> apoptosis and G1 arrest [15] and contains<br />
transactivation and repressor activities [16] . Besides TP53,<br />
the identification <strong>of</strong> PLAGL1 provides the first example<br />
<strong>of</strong> a gene which combines concomitant induction <strong>of</strong><br />
programmed cell death and cell arrest [17] .<br />
Identification <strong>of</strong> tumor specific epigenetic alterations<br />
can be used as a molecular marker <strong>of</strong> malignancy, which<br />
can lead to better diagnosis, prognosis and therapy.<br />
In this study, we evaluated the methylation status <strong>of</strong><br />
CDH1, FHIT, MTAP and PLAGL1 promoters and<br />
hypermethylation frequency as well as their association<br />
with clinico-pathological characteristics.<br />
MATERIALS AND METHODS<br />
Samples<br />
The study included 78 samples <strong>of</strong> gastric tissue. Among<br />
them, 13 were nonneoplastic gastric mucosae, including<br />
5 samples from GC patients (distant location <strong>of</strong> primary<br />
tumor) and 65 sporadic GC samples.<br />
Eight normal mucosa samples (samples 1-8) were<br />
obtained from patients undergoing upper endoscopy to<br />
check for gastritis. All these samples were obtained from<br />
the antrum <strong>of</strong> stomach biopsies. The other nonneoplastic<br />
(samples 9-13) and GC samples were surgically obtained<br />
in Pará State João de Barros Barreto University Hospital<br />
(HUJBB). Patients had never been submitted to<br />
chemotherapy or radiotherapy prior to surgery, or had any<br />
other diagnosed cancer. All patients signed an informed<br />
consent with the approval <strong>of</strong> the ethics committee <strong>of</strong><br />
HUJBB and <strong>of</strong> the Universidade Federal de São Paulo<br />
(UNIFESP). All 65 GC samples were classified according<br />
to Laurén [4] : 30 were intestinal (samples 14-43) and 35 were<br />
diffuse type (samples 44-78). Tumors were staged using<br />
standard criteria by TNM staging [<strong>18</strong>] . A rapid urease test<br />
was performed on all samples to detect H pylori.<br />
Methylation specific PCR (MSP)<br />
Genomic DNA (2 µg) was modified by bisulfite treatment,<br />
converting unmethylated cytosines to uracils and leaving<br />
methylated cytosines unchanged. MSP was performed<br />
on treated DNA as previously described [19] . Specific<br />
primers for MSP (Table 1), located within CpG islands<br />
and previously described as associated with their genes<br />
expression [20-23] , were designed with the assistance <strong>of</strong><br />
Methprimer s<strong>of</strong>tware [24] .<br />
PCR reaction was carried out in a volume <strong>of</strong> 25 µL<br />
with 200 µmol/L <strong>of</strong> dNTPs, 200 µmol/L <strong>of</strong> MgCl2,<br />
100 ng <strong>of</strong> DNA, 200 pmol/L <strong>of</strong> primers and 1 unit <strong>of</strong><br />
AmpliTaq GOLD (Applied Biosystems, Foster City, CA).<br />
Initial denaturing was carried out for 3 min at 94℃, 35<br />
cycles at 94℃ for 30 s, at different temperatures with<br />
the primers for 45 s (Table 1) and 72℃ for 30 s. This<br />
was followed by a final extension for 5 min at 72℃. PCR<br />
products were separated by 3% agarose gel containing<br />
0.0004% ethidium bromide and visualized under UV<br />
illumination (Figure 1).<br />
DNA from peripheral lymphocytes <strong>of</strong> two healthy<br />
individuals and water were used as negative controls.<br />
MSP results were scored when there was a clearly visible<br />
band on the electrophoresis gel with the methylated<br />
and unmethylatated primers [19] . Hypermethylation was<br />
considered present with methylated sequences for CDH1<br />
and FHIT promoter or only methylated sequences for<br />
MTAP and PLAGL1 promoter.<br />
Statistical analysis<br />
Statistical analyses were performed using the χ 2 test or<br />
Fisher’s exact test to assess associations between the<br />
methylation status and frequency, and clinico-pathological<br />
characteristics. P values less than 0.05 were considered<br />
significant.<br />
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Table 1 Primer sequences (5'-3') for MSP<br />
Gene Sense Antisense Product size TM<br />
CDH1 M-ATTCGAATTTAGTGGAATTAGAATC M-CCCAAAACGAAACTAACGAC 125 bp 53℃<br />
U-GGATTTGAATTTAGTGGAATTAGAATT U-CTCCCCAAAACAAAACTAACAAC 130 bp<br />
FHIT M-TTTTCGTTTTTGTTTTTAGATAAGC M-AAAAATATACCCACTAAATAACCGC 157 bp 52℃<br />
U-TGGTTTTTGTTTTTGTTTTTAGATAAGT U-AAAATATACCCACTAAATAACCACC 159 bp<br />
MTAP M-TGTTTTTTAGGAATTAAGGGAAATAC M-AACTACAAAATCTAACCCGACGAC 199 bp 52℃<br />
U-TTTTTAGGAATTAAGGGAAATATGT U-CAACTACAAAATCTAACCCAACAAC 197 bp<br />
PLAGL1 M-GTTTATTTTGGCGGAGATTTC M-ACTAAACGACACCCACACGTC 147 bp 51℃<br />
U-GGTTTATTTTGGTGGAGATTTTG U-AAAAACTAAACAACACCCACACAT 152 bp<br />
M: methylated sequences; U: unmethylated sequences; TM: melting temperature.<br />
A<br />
200<br />
150<br />
100<br />
C<br />
200<br />
150<br />
100<br />
2570 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Figure 1 Examples <strong>of</strong> gel electrophoresis using CDH1 (A), FHIT (B), MTAP (C)<br />
and PLAGL1 (D) MSP primers. L: size marker; M: methylated; U: unmethylated.<br />
RESULTS<br />
L U M U M U M<br />
+ + + + + -<br />
L U M U M U M<br />
200<br />
150<br />
100<br />
L U M U M U M<br />
+ + + + + -<br />
L U M U M U M<br />
Clinico-pathological characteristics<br />
Of the 78 patients, 54 were male and 24 were female, and<br />
their mean age was 56 ± 12.31 years (range 20-76). According<br />
to Laurén’s classification, 35 were diffuse and 30 were<br />
intestinal types. All GC samples were in advanced stage. Table<br />
2 shows cases with their clinico-pathological characteristics.<br />
There was a significant association between diffuse-type and<br />
H pylori infection in our sample (P = 0.0142).<br />
DNA hypermethylation in gastric tissue<br />
All samples analyzed showed at least one hypermethylated<br />
gene promoter. The hypermethylation frequency <strong>of</strong><br />
CDH1, FHIT, MTAP and PLAGL1 promoter were<br />
98.7%, 53.9%, 23.1% and 29.5%, respectively (Figure 2).<br />
Only one sample (sample 4), <strong>of</strong> a 20 years old patient,<br />
did not show CDH1 hypermethylation. The methylation<br />
number and frequency <strong>of</strong> CDH1, FHIT, MTAP and<br />
PLAGL1 in nonneoplastic and neoplastic samples are<br />
displayed in Table 3. Statistical analysis showed a tendency<br />
for increased PLAGL1 hypermethylation in GC samples<br />
(P = 0.0937) and in diffuse-type (P = 0.0807) compared<br />
with nonneoplastic samples.<br />
Table 4 shows the number <strong>of</strong> hypermethylated genes<br />
(1-2 or 3-4) in nonneoplastic tissue and GC samples. A<br />
tendency for hypermethylation <strong>of</strong> three or four genes in<br />
cancer samples compared to nonneoplastic samples was<br />
observed (P = 0.0959). Three or four hypermethylated<br />
genes were significantly more frequently detected in<br />
diffuse-type than in nonneoplastic mucosa (P = 0.0396).<br />
Neither <strong>of</strong> two peripheral lymphocyte samples showed<br />
hypermethylation (Figure 2).<br />
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+ + - + + +<br />
B<br />
D<br />
200<br />
150<br />
100<br />
- + + + + +<br />
Association between DNA hypermethylation and clinicopathological<br />
characteristics<br />
We analyzed whether DNA hypermethylation was<br />
associated with clinico-pathological characteristics, and<br />
detected a tendency for hypermethylation <strong>of</strong> three or four<br />
genes in tissue samples with H pylori infection (P = 0.0522).<br />
GC samples showed a significant association between higher<br />
hypermethylation frequency and H pylori infection (P =<br />
0.0428). This association was also observed in diffuse-type<br />
samples (P = 0.0033). In diffuse-type, hypermethylation<br />
<strong>of</strong> three or four genes tended to be higher in female<br />
patients than in male (P = 0.0529) and in tumors located<br />
in the noncardia stomach region (P = 0.0805). MTAP<br />
hypermethylation was associated with H pylori infection in<br />
gastric samples (P = 0.0465). MTAP hypermethylation was<br />
also associated H pylori infection in GC samples (P = 0.0175),<br />
as well as with diffuse-type compared with intestinal-type (P<br />
= 0.0249). GC samples without lymph node metastasis were<br />
associated with FHIT hypermethylation (P = 0.00<strong>18</strong>). An<br />
association was observed between absence <strong>of</strong> lymph node<br />
metastasis and FHIT hypermethylation in diffuse-type GC<br />
(P = 0.0408), as well as between female patients and MTAP<br />
hypermethylation (P = 0.0310). Absence <strong>of</strong> lymph node<br />
metastasis was associated with FHIT hypermethylation in<br />
intestinal-type GC (P = 0.0104), as well as a tendency for<br />
PLAGL1 hypermethylation and larger tumor extension (T3<br />
and T4) (P = 0.0637).<br />
DISCUSSION<br />
DNA hypermethylation in gatric tissue<br />
DNA hypermethylation <strong>of</strong> CpG islands was detected in all<br />
gastric samples, even in nonneoplastic mucosa, which can<br />
contain precursor cells for cancer and/or precancerous<br />
lesions [25] .<br />
The stomach is the organ that presents more methylated<br />
CpG island in nonneoplastic cells, along with age-related<br />
methylation that reflects increased CpG island methylation<br />
frequency in GC [26] .<br />
In our study, higher hypermethylation frequency was<br />
significantly associated with diffuse-type GC compared<br />
with nonneoplastic tissue. These findings confirmed those<br />
from Leung et al [27] , which evaluated the methylation status<br />
<strong>of</strong> 5 genes in 28 samples <strong>of</strong> GC and their corresponding<br />
nonneoplasms.<br />
We detected that 100% <strong>of</strong> GC and 92.3% <strong>of</strong> nonneo-
Leal MF et al . Promoter hypermethylation in gastric cancer 2571<br />
Samples CDH1 FHIT MTAP PLAGL1<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
7<br />
8<br />
9<br />
10<br />
11<br />
12<br />
13<br />
14<br />
15<br />
16<br />
17<br />
<strong>18</strong><br />
19<br />
20<br />
21<br />
22<br />
23<br />
24<br />
25<br />
26<br />
27<br />
28<br />
29<br />
30<br />
31<br />
32<br />
33<br />
34<br />
35<br />
36<br />
37<br />
38<br />
39<br />
40<br />
41<br />
42<br />
43<br />
44<br />
45<br />
46<br />
47<br />
48<br />
49<br />
50<br />
51<br />
52<br />
53<br />
54<br />
55<br />
56<br />
57<br />
58<br />
59<br />
60<br />
61<br />
62<br />
63<br />
64<br />
65<br />
66<br />
67<br />
68<br />
69<br />
70<br />
71<br />
72<br />
73<br />
74<br />
75<br />
76<br />
77<br />
78<br />
Limphocytes (n = 2)<br />
Figure 2 Methylation status <strong>of</strong> CDH1, FHIT, MTAP and PLAGL1 promoter in the<br />
samples studied. White boxes represent samples that showed only unmethylated<br />
sequences, gray boxes represent samples that showed unmethylated and<br />
methylatated sequences, and black boxes represent samples that showed only<br />
methylated sequences. 1-13 samples: nonneoplastic; 14-43 samples: intestinaltype<br />
GC; 44-78 samples: diffuse-type GC.<br />
plastic samples were hypermethylated in CDHI promoter<br />
(Table 3), frequencies higher than those in the literature.<br />
CDH1 methylation status was not significantly different<br />
between GC and nonneoplastic samples. This is the first<br />
study thay has evaluated CDH1 methylation frequency in<br />
Table 2 Clinico-pathological characteristics <strong>of</strong> the samples<br />
Samples<br />
Variable (n ) Nonneoplastic Intestinal Diffuse P<br />
n (%) n (%) n (%)<br />
Gender<br />
Male (54) 9 (16.67) 20 (37.03) 25 (46.3) 0.9176<br />
Female (24) 4 (16.66) 10 (41.67) 10 (41.67)<br />
Age (yr)<br />
≤ 50 (23) 7 (30.43) 7 (30.43) 9 (39.14) 0.1056<br />
> 50 (55) 6 (10.91) 23 (41.82) 26 (47.27)<br />
Smoking status<br />
Smoker (27) 1 (3.7) 13 (48.15) 13 (48.15) 0.0717<br />
No smoker (51) 12 (23.53) 17 (33.33) 22 (43.14)<br />
H pylori<br />
Present (36) 6 (16.67) 8 (22.22) 22 (61.11) 0.0142 a<br />
Absent (42) 7 (16.67) 22 (52.38) 13 (30.95)<br />
Location<br />
Cardia (25) - 11 (44) 14 (56) 0.783<br />
Noncardia (40) - 19 (47.5) 21 (52.5)<br />
T stage<br />
T1, T2 (15) - 7 (46.67) 8 (53.33) 0.9638<br />
T3, T4 (50) - 23 (46) 27 (54)<br />
Lymph node metastasis<br />
Present (51) - 23 (45.1) 28 (54.9) 0.7445<br />
Absent (14) - 7 (50) 7 (50)<br />
Distant metastasis<br />
Present (6) - 4 (66.67) 2 (33.33) 0.4649<br />
Absent (55) - 23 (41.82) 32 (58.<strong>18</strong>)<br />
Unknown (4) - 3 (75%) 1 (25%)<br />
a P < 0.05.<br />
gastric tissue samples from a Brazilian population.<br />
The highest CDH1 hypermethylation frequency<br />
described in the literature was 90% in advanced GC<br />
samples [28] , as well as in nonneoplastic tissue [29] . However,<br />
Zazula et al [29] did not find significant differences between<br />
methylation patterns in 84 GC samples and their nonneoplastic<br />
controls.<br />
Waki et al [30] evaluated CDH1 methylation status in<br />
nonneoplastic gastric mucosa samples at autopsies. The<br />
authors did not see this gene methylation in nonneoplastic<br />
gastric cells from people who were 22 years and younger.<br />
However, CDH1 methylation was found in 86% <strong>of</strong><br />
nonneoplastic gastric epithelia <strong>of</strong> people who were over<br />
45 years old. Our findings showed only one nonneoplastic<br />
sample without CDH1 methylation from a 20 years old<br />
patient. Thus, our findings confirm those from Waki’s<br />
study. The incidence <strong>of</strong> GC rises with age, pointing<br />
to an association between age-related methylation and<br />
GC development [30,31] . CDH1 hypermethylation in<br />
nonneoplastic gastric epithelia has also been frequently<br />
associated with H pylori infection [31-33] .<br />
In our sample, higher CDH1 hypermethylation<br />
frequency may result from the association <strong>of</strong> age, H pylori<br />
infection, advanced tumor and epidemiological factors,<br />
such as genetics constitution and diet.<br />
In our study, FHIT hypermethylation frequency was<br />
52.3% in GC samples (Table 2). This value is lower than<br />
those from two GC studies in the literature [34,35] . On the<br />
other hand, the FHIT hypermethylation frequency was<br />
61.5% in nonneoplastic samples, which is higher than<br />
in other studies. Roa et al [34] reported that FHIT was<br />
methylated in 62% <strong>of</strong> 47 GC samples. Schildhaus et al [35]<br />
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2572 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Table 3 Methylation number and frequency in gastric tissue samples, n (%)<br />
Samples<br />
Methylation status<br />
observed FHIT hypermethylation in all 6 advanced<br />
proximal GC and in 40% (2 <strong>of</strong> 5 samples) <strong>of</strong> normal<br />
gastric tissue, suggesting the FHIT hypermethylation is a<br />
precursor for GC.<br />
In our study, FHIT promoter hypermethylation was<br />
detected in 80% (8/10) <strong>of</strong> nonneoplastic samples with<br />
gastritis or from GC patients, whereas none <strong>of</strong> the 3<br />
nonneoplastic samples from subjects without gastritis and<br />
without GC were methylated (data not shown). Our findings<br />
suggest that FHIT hypermethylation may be associated<br />
with the start <strong>of</strong> gastric carcinogenesis, as well as in other<br />
organs [36] .<br />
Unmethylated sequences together with methylated<br />
sequences in CDH1 and FHIT promoter may be a<br />
result <strong>of</strong> allelic heterozygosity, clonal heterogeneity or<br />
contamination by inflammatory cells or stromal.<br />
The methylation status <strong>of</strong> the MTAP promoter has<br />
never been analyzed in gastric tissue samples, while<br />
this promoter has been described in other neoplasias.<br />
However, methylation in nonneoplastic tissues has never<br />
been described [22,37-40] . Similarly, the MTAP promoter<br />
hypermethylation has never been analyzed by MSP. We<br />
detected methylated sequences for MTAP promoter in<br />
all samples, including nonneoplastic and lymphocytes<br />
samples. Thus, the difference found between MTAP<br />
methylation status in our work and those from the<br />
literature may be due to different CpG islands analyzed, as<br />
well as methodological differences.<br />
We considered the MTAP promoter hypermethylation<br />
when only methylated sequences were observed, comparing<br />
with the methylation status in peripheral blood<br />
lymphocytes. The MTAP promoter hypermethylation was<br />
in 24.6% <strong>of</strong> GC and 15.4% <strong>of</strong> nonneoplastic samples<br />
(Table 3).<br />
In all samples methylated sequences <strong>of</strong> PLAGL1 was<br />
also observed, including nonneoplastic and lymphocyte<br />
CDH1 FHIT MTAP PLAGL1<br />
M/U U M/U U M/U M P M/U M<br />
Normal tissue (13) 12 (92.31) 1 (7.69) 8 (61.54) 5 (38.46) 11 (84.62) 2 (15.38) 12 (92.31) 1 (7.69)<br />
GC (65) 65 (100) 0 (0) 34 (52.31) 31 (47.69) 49 (75.38) 16 (24.62) 43 (66.15) 22 (33.85)<br />
Diffuse-type GC (35) 35 (100) 0 (0) 17 (48.57) <strong>18</strong> (56.25) 22 (62.86) 13 (37.14) 0.0249 a<br />
23 (65.71) 12(34.29)<br />
Intestinal-type GC (30) 30 (100) 0 (0) 17 (56.67) 13 (43.33) 27 (90) 3 (10) 20 (66.6) 10 (33.33)<br />
U: unmethylated; M/U: methylated and unmethylated; M: methylated. a P < 0.05 vs Intestinal-type GC.<br />
Table 4 Number <strong>of</strong> hypermethylated genes in gastric tissue samples<br />
Samples (N)<br />
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Number <strong>of</strong> hypermethylated genes P<br />
value<br />
1 or 2 3 or 4<br />
Nonneplastic gastric tissue (13) 12 (92.31%) 1 (7.69%)<br />
Gastric cancer (65) 44 (67.69%) 21 (32.31%) 0.0396 b<br />
Diffuse-type GC (35) 21 (60%) 14 (40%)<br />
Intestinal-type GC (30) 23 (76.67%) 7 (23.33%)<br />
N: number <strong>of</strong> cases; b P < 0.05.<br />
samples. The literature shows only one study that evaluated<br />
PLAGL1 methylation status in gastric samples [23] , where<br />
MSP was perfomed for PLAGL1 in 5 GC cell lines,<br />
10 primary GC and one nonneoplastic sample. The<br />
authors observed methylation sequences in all neoplastic<br />
samples, while only one sample showed methylated and<br />
unmethylated sequences. The nonneoplastic sample<br />
presented only unmethylated sequences.<br />
Our findings did not confirm those <strong>of</strong> Yamashita et al [23]<br />
for the nonneoplastic sample. However, PLAGL1<br />
has been described as a maternal imprinted gene and<br />
hypermethylation leads to transcriptional silencing, as<br />
reported in other neoplasias [41] . Considered an imprinted<br />
gene, we found PLAGL1 hypermethylation in 33.9% <strong>of</strong><br />
GC and 7.7% <strong>of</strong> nonneoplastic gastric samples (Table 3).<br />
Association between DNA hypermethylation and clinicopathological<br />
characteristics<br />
In our study, a higher hypermethylation frequency <strong>of</strong> CpG<br />
islands was found in H pylori infected samples, confirming<br />
findings from studies by El-Omar et al [42,43] and Hmadcha<br />
et al [44] . El-Omar et al [42,43] reported that interleukin-1β<br />
polymorphism led to an upregulation <strong>of</strong> interleukin-1β<br />
with H pylori infection and was associated with increased<br />
risk <strong>of</strong> GC. Furthermore, Hmadcha et al [44] described that<br />
interleukin-1β might induce gene methylation through<br />
the production <strong>of</strong> nitric oxide and the subsequent<br />
activation <strong>of</strong> DNA methyltransferase. It is possible that<br />
H pylori induces methylation through the production <strong>of</strong><br />
interleukin-1β and hence the downstream activation <strong>of</strong><br />
nitric oxide and DNA methyltransferase [31] .<br />
A higher hypermethylation frequency was associated<br />
with H pylori in diffuse-type, which can be related to its<br />
higher incidence in our samples <strong>of</strong> diffuse-type GC. H pylori<br />
gastritis is the only known precursor for diffuse-type<br />
GC [45] .<br />
In our study, a higher MTAP hypermethylation frequency<br />
was also associated with H pylori infection in gastric samples,<br />
especially in diffuse-type. MTAP hypermethylation in<br />
diffuse-type that is associated with H pylori infection may be<br />
due to a genetic predisposition. An association with female<br />
patients was also observed, which may be related to diffusetype<br />
incidence, that is more frequent in female patients [46] .<br />
In our study, GC samples without lymph node<br />
metastasis were associated with FHIT hypermethylation.<br />
However, because <strong>of</strong> the small number <strong>of</strong> samples without<br />
lymph node metastasis in our study, further studies are
Leal MF et al . Promoter hypermethylation in gastric cancer 2573<br />
necessary to confirm this association.<br />
This is the first study that has evaluated the methylation<br />
status <strong>of</strong> CDH1, FHIT, MTAP and PLAGL1<br />
promoters and their hypermethylation frequencies in<br />
gastric tissue samples in a population from Northern<br />
Brazil. The methylation status <strong>of</strong> MTAP promoter has<br />
never been investigated in gastric samples. Our findings<br />
show that hypermethylation is associated with gastric<br />
carcinogenesis. The H pylori infectious agent was present<br />
in 44.9% <strong>of</strong> samples and this infection may be a part <strong>of</strong><br />
the carcinogenesis process through the gene promoter<br />
hypermethylation; especially the MTAP promoter in<br />
diffuse-type. Increased H pylori infection in diffuse-type<br />
may also be due to higher genetic predisposition.<br />
REFERENCES<br />
1 Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics,<br />
2002. CA Cancer J Clin 2005; 55: 74-108<br />
2 Cancer Databases and Other Resourcess. International<br />
Agency for Research on Cancer (IARC) page. Available from<br />
URL: http://www.iarc.fr<br />
3 Pereira LP, Waisberg J, Andre EA, Zanoto A, Mendes Junior<br />
JP, Soares HP. Detection <strong>of</strong> Helicobacter pylori in gastric<br />
cancer. Arq Gastroenterol 2001; 38: 240-246<br />
4 Lauren P. The Two Histological Main Types <strong>of</strong> Gastric<br />
Carcinoma: Diffuse and So-Called Intestinal-Type Carcinoma.<br />
an Attempt at a Histo-Clinical Classification. Acta Pathol<br />
Microbiol Scand 1965; 64: 31-49<br />
5 Huntsman DG, Carneiro F, Lewis FR, MacLeod PM, Hayashi<br />
A, Monaghan KG, Maung R, Seruca R, Jackson CE, Caldas C.<br />
Early gastric cancer in young, asymptomatic carriers <strong>of</strong> germline<br />
E-cadherin mutations. N Engl J Med 2001; 344: 1904-1909<br />
6 Bird A. DNA methylation patterns and epigenetic memory.<br />
Genes Dev 2002; 16: 6-21<br />
7 Birchmeier W, Behrens J. Cadherin expression in carcinomas:<br />
role in the formation <strong>of</strong> cell junctions and the prevention <strong>of</strong><br />
invasiveness. Biochim Biophys Acta 1994; 1198: 11-26<br />
8 Chan AO. E-cadherin in gastric cancer. <strong>World</strong> J Gastroenterol<br />
2006; 12: 199-203<br />
9 Ohta M, Inoue H, Cotticelli MG, Kastury K, Baffa R, Palazzo J,<br />
Siprashvili Z, Mori M, McCue P, Druck T, Croce CM, Huebner<br />
K. The FHIT gene, spanning the chromosome 3p14.2 fragile<br />
site and renal carcinoma-associated t(3;8) breakpoint, is<br />
abnormal in digestive tract cancers. Cell 1996; 84: 587-597<br />
10 Pekarsky Y, Palamarchuk A, Huebner K, Croce CM. FHIT as<br />
tumor suppressor: mechanisms and therapeutic opportunities.<br />
Cancer Biol Ther 2002; 1: 232-236<br />
11 Hori H, Tran P, Carrera CJ, Hori Y, Rosenbach MD, Carson<br />
DA, Nobori T. Methylthioadenosine phosphorylase cDNA<br />
transfection alters sensitivity to depletion <strong>of</strong> purine and<br />
methionine in A549 lung cancer cells. Cancer Res 1996; 56:<br />
5653-5658<br />
12 Subhi AL, Diegelman P, Porter CW, Tang B, Lu ZJ, Markham<br />
GD, Kruger WD. Methylthioadenosine phosphorylase regulates<br />
ornithine decarboxylase by production <strong>of</strong> downstream<br />
metabolites. J Biol Chem 2003; 278: 49868-49873<br />
13 Okuzumi J, Yamane T, Kitao Y, Tokiwa K, Yamaguchi T,<br />
Fujita Y, Nishino H, Iwashima A, Takahashi T. Increased<br />
mucosal ornithine decarboxylase activity in human gastric<br />
cancer. Cancer Res 1991; 51: 1448-1451<br />
14 Wild PJ, Meyer S, Bataille F, Woenckhaus M, Ameres M,<br />
Vogt T, Landthaler M, Pauer A, Klinkhammer-Schalke M,<br />
H<strong>of</strong>staedter F, Bosserh<strong>of</strong>f AK. Tissue microarray analysis <strong>of</strong><br />
methylthioadenosine phosphorylase protein expression in<br />
melanocytic skin tumors. Arch Dermatol 2006; 142: 471-476<br />
15 Spengler D, Villalba M, H<strong>of</strong>fmann A, Pantaloni C, Houssami<br />
S, Bockaert J, Journot L. Regulation <strong>of</strong> apoptosis and cell cycle<br />
arrest by Zac1, a novel zinc finger protein expressed in the<br />
pituitary gland and the brain. EMBO J 1997; 16: 2814-2825<br />
16 H<strong>of</strong>fmann A, Ciani E, Boeckardt J, Holsboer F, Journot L,<br />
Spengler D. Transcriptional activities <strong>of</strong> the zinc finger protein<br />
Zac are differentially controlled by DNA binding. Mol Cell Biol<br />
2003; 23: 988-1003<br />
17 Kas K, Voz ML, Hensen K, Meyen E, Van de Ven WJ.<br />
Transcriptional activation capacity <strong>of</strong> the novel PLAG family<br />
<strong>of</strong> zinc finger proteins. J Biol Chem 1998; 273: 23026-23032<br />
<strong>18</strong> Sobin LH, Wittekind CH. TNM classification <strong>of</strong> malignant<br />
tumours. 6th ed. New York: Wiley-Liss, 2002<br />
19 Herman JG, Graff JR, Myohanen S, Nelkin BD, Baylin SB.<br />
Methylation-specific PCR: a novel PCR assay for methylation<br />
status <strong>of</strong> CpG islands. Proc Natl Acad Sci USA 1996; 93: 9821-9826<br />
20 Oue N, Mitani Y, Motoshita J, Matsumura S, Yoshida K,<br />
Kuniyasu H, Nakayama H, Yasui W. Accumulation <strong>of</strong> DNA<br />
methylation is associated with tumor stage in gastric cancer.<br />
Cancer 2006; 106: 1250-1259<br />
21 Tanaka H, Shimada Y, Harada H, Shinoda M, Hatooka S,<br />
Imamura M, Ishizaki K. Methylation <strong>of</strong> the 5' CpG island<br />
<strong>of</strong> the FHIT gene is closely associated with transcriptional<br />
inactivation in esophageal squamous cell carcinomas. Cancer<br />
Res 1998; 58: 3429-3434<br />
22 Behrmann I, Wallner S, Komyod W, Heinrich PC, Schuierer<br />
M, Buettner R, Bosserh<strong>of</strong>f AK. Characterization <strong>of</strong><br />
methylthioadenosin phosphorylase (MTAP) expression in<br />
malignant melanoma. Am J Pathol 2003; 163: 683-690<br />
23 Yamashita S, Tsujino Y, Moriguchi K, Tatematsu M, Ushijima T.<br />
Chemical genomic screening for methylation-silenced genes in<br />
gastric cancer cell lines using 5-aza-2'-deoxycytidine treatment<br />
and oligonucleotide microarray. Cancer Sci 2006; 97: 64-71<br />
24 Li LC, Dahiya R. MethPrimer: designing primers for methylation<br />
PCRs. Bioinformatics 2002; <strong>18</strong>: 1427-1431<br />
25 Etoh T, Kanai Y, Ushijima S, Nakagawa T, Nakanishi Y, Sasako<br />
M, Kitano S, Hirohashi S. Increased DNA methyltransferase 1<br />
(DNMT1) protein expression correlates significantly with poorer<br />
tumor differentiation and frequent DNA hypermethylation <strong>of</strong><br />
multiple CpG islands in gastric cancers. Am J Pathol 2004; 164:<br />
689-699<br />
26 Esteller M. CpG island hypermethylation and tumor<br />
suppressor genes: a booming present, a brighter future.<br />
Oncogene 2002; 21: 5427-5440<br />
27 Leung WK, Yu J, Ng EK, To KF, Ma PK, Lee TL, Go MY,<br />
Chung SC, Sung JJ. Concurrent hypermethylation <strong>of</strong> multiple<br />
tumor-related genes in gastric carcinoma and adjacent normal<br />
tissues. Cancer 2001; 91: 2294-2301<br />
28 Zheng ZH, Sun XJ, Ma MC, Hao DM, Liu YH, Sun KL. Studies<br />
<strong>of</strong> promoter methylation status and protein expression <strong>of</strong><br />
E-cadherin gene in associated progression stages <strong>of</strong> gastric<br />
cancer. Yichuan Xuebao 2003; 30: 103-108<br />
29 Zazula M, Ferreira AM, Czopek JP, Kolodziejczyk P, Sinczak-<br />
Kuta A, Klimkowska A, Wojcik P, Okon K, Bialas M, Kulig J,<br />
Stachura J. CDH1 gene promoter hypermethylation in gastric<br />
cancer: relationship to Goseki grading, microsatellite instability<br />
status, and EBV invasion. Diagn Mol Pathol 2006; 15: 24-29<br />
30 Waki T, Tamura G, Tsuchiya T, Sato K, Nishizuka S,<br />
Motoyama T. Promoter methylation status <strong>of</strong> E-cadherin,<br />
hMLH1, and p16 genes in nonneoplastic gastric epithelia. Am J<br />
Pathol 2002; 161: 399-403<br />
31 Chan AO, Lam SK, Wong BC, Wong WM, Yuen MF, Yeung<br />
YH, Hui WM, Rashid A, Kwong YL. Promoter methylation <strong>of</strong><br />
E-cadherin gene in gastric mucosa associated with Helicobacter<br />
pylori infection and in gastric cancer. Gut 2003; 52: 502-506<br />
32 Liu YC, Shen CY, Wu HS, Chan DC, Chen CJ, Yu JC, Yu CP,<br />
Harn HJ, Shyu RY, Shih YL, Hsieh CB, Hsu HM. Helicobacter<br />
pylori infection in relation to E-cadherin gene promoter<br />
polymorphism and hypermethylation in sporadic gastric<br />
carcinomas. <strong>World</strong> J Gastroenterol 2005; 11: 5174-5179<br />
33 Leung WK, Man EP, Yu J, Go MY, To KF, Yamaoka Y, Cheng<br />
VY, Ng EK, Sung JJ. Effects <strong>of</strong> Helicobacter pylori eradication<br />
on methylation status <strong>of</strong> E-cadherin gene in noncancerous<br />
stomach. Clin Cancer Res 2006; 12: 3216-3221<br />
34 Roa JC, Anabalon L, Roa I, Tapia O, Melo A, Villaseca M,<br />
Araya JC. Promoter methylation pr<strong>of</strong>ile in gastric cancer. Rev<br />
Med Chil 2005; 133: 874-880<br />
www.wjgnet.com
2574 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
35 Schildhaus HU, Krockel I, Lippert H, Malfertheiner P,<br />
Roessner A, Schneider-Stock R. Promoter hypermethylation<br />
<strong>of</strong> p16INK4a, E-cadherin, O6-MGMT, DAPK and FHIT in<br />
adenocarcinomas <strong>of</strong> the esophagus, esophagogastric junction<br />
and proximal stomach. Int J Oncol 2005; 26: 1493-1500<br />
36 Sozzi G, Pastorino U, Moiraghi L, Tagliabue E, Pezzella<br />
F, Ghirelli C, Tornielli S, Sard L, Huebner K, Pierotti MA,<br />
Croce CM, Pilotti S. Loss <strong>of</strong> FHIT function in lung cancer and<br />
preinvasive bronchial lesions. Cancer Res 1998; 58: 5032-5037<br />
37 Berasain C, Hevia H, Fernandez-Irigoyen J, Larrea E, Caballeria<br />
J, Mato JM, Prieto J, Corrales FJ, Garcia-Trevijano ER, Avila<br />
MA. Methylthioadenosine phosphorylase gene expression<br />
is impaired in human liver cirrhosis and hepatocarcinoma.<br />
Biochim Biophys Acta 2004; 1690: 276-284<br />
38 Furuta J, Umebayashi Y, Miyamoto K, Kikuchi K, Otsuka F,<br />
Sugimura T, Ushijima T. Promoter methylation pr<strong>of</strong>iling <strong>of</strong><br />
30 genes in human malignant melanoma. Cancer Sci 2004; 95:<br />
962-968<br />
39 Hellerbrand C, Muhlbauer M, Wallner S, Schuierer M, Behrmann<br />
I, Bataille F, Weiss T, Scholmerich J, Bosserh<strong>of</strong>f AK. Promoterhypermethylation<br />
is causing functional relevant downregulation<br />
<strong>of</strong> methylthioadenosine phosphorylase (MTAP) expression in<br />
hepatocellular carcinoma. Carcinogenesis 2006; 27: 64-72<br />
www.wjgnet.com<br />
40 Wang Y, Yu Q, Cho AH, Rondeau G, Welsh J, Adamson E,<br />
Mercola D, McClelland M. Survey <strong>of</strong> differentially methylated<br />
promoters in prostate cancer cell lines. Neoplasia 2005; 7: 748-760<br />
41 Abdollahi A. LOT1 (ZAC1/PLAGL1) and its family members:<br />
mechanisms and functions. J Cell Physiol 2007; 210: 16-25<br />
42 El-Omar EM, Carrington M, Chow WH, McColl KE, Bream<br />
JH, Young HA, Herrera J, Lissowska J, Yuan CC, Rothman N,<br />
Lanyon G, Martin M, Fraumeni JF Jr, Rabkin CS. Interleukin-1<br />
polymorphisms associated with increased risk <strong>of</strong> gastric<br />
cancer. Nature 2000; 404: 398-402<br />
43 El-Omar EM, Rabkin CS, Gammon MD, Vaughan TL, Risch<br />
HA, Schoenberg JB, Stanford JL, Mayne ST, Goedert J, Blot<br />
WJ, Fraumeni JF Jr, Chow WH. Increased risk <strong>of</strong> noncardia<br />
gastric cancer associated with proinflammatory cytokine gene<br />
polymorphisms. <strong>Gastroenterology</strong> 2003; 124: 1193-1201<br />
44 Hmadcha A, Bedoya FJ, Sobrino F, Pintado E. Methylationdependent<br />
gene silencing induced by interleukin 1beta via<br />
nitric oxide production. J Exp Med 1999; 190: 1595-1604<br />
45 Vauhkonen M, Vauhkonen H, Sipponen P. Pathology<br />
and molecular biology <strong>of</strong> gastric cancer. Best Pract Res Clin<br />
Gastroenterol 2006; 20: 651-674<br />
46 Yuasa Y. Control <strong>of</strong> gut differentiation and intestinal-type<br />
gastric carcinogenesis. Nat Rev Cancer 2003; 3: 592-600<br />
S- Editor Liu Y L- Editor Roberts SE E- Editor Wang HF
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2575-2580<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
A preliminary study <strong>of</strong> neck-stomach syndrome<br />
Xing-Hua Song, Xiao-Xiong Xu, Li-Wen Ding, Li Cao, Alken Sadel, Hao Wen<br />
Xing-Hua Song, Xiao-xiong Xu, Li Cao, Alken Sadel,<br />
Department <strong>of</strong> Orthopaedics, the First Affiliated Hospital,<br />
Xinjiang Medical University, Urumqi 830054, Xinjiang Uighur<br />
Autonomous Region, China<br />
Li-Wen Ding, Teaching Department, the First Affiliated Hospital,<br />
Xinjiang Medical University, Urumqi 830054, Xinjiang Uighur<br />
Autonomous Region, China<br />
Hao Wen, Xinjiang Clinical Hydatid Research Institute and<br />
General Department, the First Affiliated Hospital <strong>of</strong> Xinjiang<br />
Medical University, Urumqi 830054, Xinjiang Uighur Autonomous<br />
Region, China<br />
Supported by the Science Foundation <strong>of</strong> Chinese Post-doctor<br />
Correspondence to: Hao Wen, Xinjiang Clinical Hydatid<br />
Research Institute and General Department, the First Affiliated<br />
Hospital <strong>of</strong> Xinjiang Medical University, No. 1, LiYuShan Road,<br />
Urumqi 830054, Xinjiang Uighur Autonomous Region,<br />
China. wenh19@163.com<br />
Telephone: +86-991-4363775 Fax: +86-991-4324139<br />
Received: 2007-03-08 Accepted: 2006-03-31<br />
Abstract<br />
AIM: To determine the expression <strong>of</strong> c-Fos, caspase-3<br />
and interleukin-1β (IL-1β) in the cervical cord and<br />
stomach <strong>of</strong> rats with cervical spondylosis, to analyze<br />
their relationship, and to <strong>of</strong>fer an explanation <strong>of</strong> one<br />
possible cause for functional dyspepsia (FD) and irritable<br />
bowel syndrome (IBS) caused by cervical spondylosis.<br />
METHODS: The cervical spondylosis model in rats<br />
was established by destroying the stability <strong>of</strong> cervical<br />
posterior column. The cord segments C4-6 and gastric<br />
antrum were collected 3 mo and 5 mo after the<br />
operation. Rats with the sham operation were used as<br />
controls. The expressions <strong>of</strong> c-Fos, caspase-3 and IL-1β<br />
in the cervical cord and gastric antrum were determined<br />
by immunohistochemistry and/or Western blot.<br />
RESULTS: Immunohistochemical staining showed a few<br />
c-Fos, caspase-3 and IL-1β-positive cells in the cervical<br />
cord and antrum in the control. There was a significant<br />
increase in c-Fos, caspase-3 and IL-1β expression in<br />
model groups compared to the control groups at 3 mo<br />
and 5 mo after operation. More importantly, there was<br />
a significant (P < 0.05) increase in c-Fos, caspase-3<br />
and IL-1β expression in the model group rats at 3 mo<br />
compared to those at 5 mo after the operation (c-Fos:<br />
11.20 ± 2.26 vs 27.68 ± 4.36 in the cervical cord, 11.3 ±<br />
2.3 vs 29.3 ± 4.6 in the gastric antrum; caspase-3: 33.83<br />
± 3.71 vs 36.32 ± 4.01 in the cervical cord, 13.23 ± 3.21<br />
vs 26.32 ± 4.01 in the gastric antrum; IL-1β: 42.06 ±<br />
2.95 vs 45.91 ± 3.98 in the cervical cord, 26.56 ± 2.65<br />
vs 32.01 ± 2.98 in the gastric antrum). Western blot<br />
CLINICAL RESEARCH<br />
analysis showed time-dependent changes <strong>of</strong> caspase-3<br />
and IL-1β protein in the cervical cord and gastric antrum<br />
<strong>of</strong> rats with cervical spondylosis; there was no significant<br />
expression <strong>of</strong> caspase-3 and IL-1β protein in the control<br />
group at 3 mo and 5 mo after the sham operation,<br />
whereas there was a significant difference in caspase-3<br />
and IL-1β protein levels between the model group rats<br />
followed up for 3 mo and those for 5 mo (P < 0.05).<br />
CONCLUSION: There is a significant association <strong>of</strong><br />
c-Fos, caspase-3 and IL-1β expressions in the gastric<br />
antrum with that in the spinal cord in rats with cervical<br />
spondylosis, suggesting that the gastrointestinal function<br />
may be affected by cervical spondylosis.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Caspase-3; IL-1β; c-Fos; Cervical spondylosis;<br />
Gastric antrum<br />
Song XH, Xu XX, Ding LW, Cao L, Sadel A, Wen H. A<br />
preliminary study <strong>of</strong> neck-stomach syndrome. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2575-2580<br />
http://www.wjgnet.com/1007-9327/13/2575.asp<br />
INTRODUCTION<br />
Many patients with cervical spondylosis complain <strong>of</strong><br />
gastrointestinal symptoms. Some are caused by NSAIDs,<br />
but many patients are not taking any medication. There<br />
is a direct or indirect relationship between the neck and<br />
the stomach, called the neck-stomach syndrome. Cervical<br />
pathology, mediated through sympathetic nerves, has been<br />
associated with a number <strong>of</strong> disorders, which include<br />
about 20 kinds <strong>of</strong> diseases or symptom-groups, such as<br />
hypertension, cardiac arrhythmias, dizziness, eyesight<br />
malfunction and gastrointestinal dysfunction. Perhaps<br />
the clinical symptoms <strong>of</strong> cervical spondylosis include<br />
gastrointestinal disorders mediated through irritated<br />
sympathetic nerves. A study reported such a mechanism [1] ,<br />
but <strong>of</strong>fered no supportive evidence. In the present report,<br />
expression <strong>of</strong> c-Fos, caspase-3 and IL-1β in the cervical<br />
cord and gastric antrum were examined in rats with<br />
cervical spondylosis and the results were analyzed. If the<br />
longer duration the cervical vertebrae degeneration is<br />
correlated with the increasing levels <strong>of</strong> c-Fos, caspase-3<br />
and IL-1β in the cord and in the stomach, then the<br />
hypothesis might be validated.<br />
c-fos is a proto-oncogene or a cellular oncogene,<br />
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2576 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
which exists extensively in genomes <strong>of</strong> eukaryotes. It<br />
participates in normal cell growth and proliferation and<br />
regulates message transfer in cells. Most previous studies<br />
have focused on c-Fos expression that is induced by the<br />
controlled and natural irritations [2-4] Recently, it has been<br />
proven that the normal motion <strong>of</strong> the digestive tube relies<br />
on reflex activity controlled by extrinsic nerves and enteric<br />
nervous system (ENS). c-Fos as the third messenger,<br />
which regulates the target gene, provides a reliable and<br />
direct method to study the mechanism <strong>of</strong> functional<br />
gastrointestinal diseases [5] . Our previous study [6] reported<br />
that the c-Fos expression in the gastric myenteric plexus<br />
was dramatically associated with c-Fos expression <strong>of</strong> the<br />
spinal cord in the rats with cervical spondylosis. It is the<br />
sympathetic nerve that results in the c-Fos expression<br />
both in the spinal cord and the gastric myenteric plexus<br />
in cervical spondylosis and this suggests that the<br />
gastrointestinal function may be affected by cervical<br />
spondylosis. To provide further evidence, c-Fos, caspase-3<br />
and IL-1β were detected in the cord and stomach. The<br />
rationale being that caspase-3 is a potential mediator <strong>of</strong><br />
apoptosis after central nerve system (CNS) injury [7,8] and<br />
its activation may be used as a marker <strong>of</strong> apoptotic cell<br />
death. Several studies have provided evidence that cell<br />
death from moderately severe spinal cord injury (SCI) is<br />
regulated, in part, by apoptosis that involves the caspase<br />
family <strong>of</strong> cysteine proteases [8,9] . In the hippocampus <strong>of</strong><br />
aged rats, the concentration <strong>of</strong> IL-1β is increased and this<br />
increase is accompanied by enhanced caspase-3 activity<br />
indicative <strong>of</strong> cell death [10] . These findings suggest that<br />
neuronal apoptosis in the CNS is induced by increased<br />
IL-1β through the activity <strong>of</strong> the caspase-3 apoptotic<br />
pathway. IL-1β induced apoptosis in neurons in vitro [11]<br />
and in cultured human astrocytes [12] and oligodendrocytes<br />
in vivo [13] .<br />
In the present study, after establishing the cervical<br />
spondylosis model <strong>of</strong> rats according to a previously<br />
described method [6] , the cord and stomach were collected<br />
at 3 mo and 5 mo to determine the expression <strong>of</strong> c-Fos,<br />
caspase-3 and IL-1β in the cervical cord and gastric<br />
antrum by immunohistochemistry and/or Western blot.<br />
MATERIALS AND METHODS<br />
Animal models<br />
Ninety-six four-month-old Sprague Dawley rats (provided<br />
by the Experimental Animal Center <strong>of</strong> Shantou University<br />
Medical College, Shantou, China), weighting 250 g (range,<br />
220-280 g), were used in this study. The rats were randomly<br />
divided into model and control groups and fed a normal<br />
diet, with eight in one big cage, and kept for 3 mo and 5<br />
mo, respectively, after the experimental or sham operations<br />
as described below. Each group consisted <strong>of</strong> 12 male and<br />
12 female rats at each time point.<br />
The rats in the model group were anesthetized<br />
by intraperitoneal (ip) injection <strong>of</strong> 40 mg/kg sodium<br />
pentobarbital . The dorsal neck was shaved and a<br />
longitudinal incision about 2.5 cm was made. The dorsal<br />
muscles were reserved, the spinal processes were removed,<br />
as well as the inter-spinal ligaments, the capsule <strong>of</strong> articular<br />
www.wjgnet.com<br />
processes and part <strong>of</strong> the superior and inferior articular<br />
processes between C3-7 levels were removed till the<br />
movement between the neighboring superior and inferior<br />
laminae was obviously increased after the operation, and<br />
the incision was closed. Three and five months after<br />
the operation, the models were confirmed by evaluating<br />
X-ray films and the motion function with oblique board<br />
test according to the previous studies [14,15] . X-ray films<br />
showed disappeared or stiff nature cervical curve, stenosis<br />
<strong>of</strong> the vertebral space and osteosis spur in the model<br />
groups compared with the control groups. To test motion<br />
function, the rats were put on a tilted board, and the angle<br />
between the board and horizontal plane was recorded,<br />
which showed a significant difference in control groups<br />
and model groups. The rats in the control group (sham<br />
operation group) had only a longitudinal incision on the<br />
dorsal neck which was closed without further intervention.<br />
Immunohistochemistry<br />
The rats were euthanized with a lethal dose <strong>of</strong><br />
pentobarbital sodium (100 mg/kg) and perfused via<br />
cardiac puncture with 0.1 mol/L phosphate-buffered<br />
saline (PBS) (pH 7.4; 150 mL) and subsequently with 40%<br />
paraformaldehyde in 0.1 mol/L PBS (250 mL). The cord<br />
and gastric antrum tissues were dissected out and postfixed<br />
by immersion in 40 mL/L paraformaldehyde for 3 h<br />
and then cryoprotected by immersion in 200 g/L sucrose<br />
(in PBS) overnight. Tissue segments were embedded in<br />
Tissue-Tek O.C.T. (Lab-Tek Division, Miles Lab, Inc.) and<br />
frozen as previously described [16] . Free-floating transverse<br />
sections (10 μm) were cut with a cryostat.<br />
Immunohistochemical staining was carried out<br />
using the avidin–biotin complex method as previously<br />
described [6,17] . The concentrations for rabbit anti-IL-<br />
1β, rabbit anti-caspase-3 and rabbit polyclonal anti-c-fos<br />
primary antibodies were 1:200, 1:200 (Sigma, Genetimes<br />
Technology Inc.) and 1:100 000 (diluted in NGS-T-<br />
PBS). Positive immunoreactive labeling was observed<br />
qualitatively.<br />
The method for gastric neuronal counterstaining was<br />
adapted from previous studies [6,<strong>18</strong>,19] . c-Fos cells were<br />
counted under microscopy in 25 ganglia from each antral<br />
preparation and expressed as a mean percentage count per<br />
myenteric ganglion. Myenteric ganglia were recognized as<br />
clearly delineated groups <strong>of</strong> neurons separated by welldefined<br />
internodal fiber tracts. The mean from all animals<br />
in each group was used to calculate the group mean. Data<br />
were expressed as mean ± SD <strong>of</strong> the number <strong>of</strong> cells<br />
or neurons per ganglion. Buffy spots or particles in cells<br />
were regarded as positive expression <strong>of</strong> caspase-3 and IL-<br />
1β. The random sections were observed under the optical<br />
microscope at 200 × magnification, the positive cells were<br />
counted in ten random visual fields, and then the mean in<br />
each group was calculated.<br />
Western blot analysis<br />
At 3 mo and 5 mo after the destabilizing operation,<br />
an 8 mm spinal cord segment was dissected 4 mm<br />
rostral and 4 mm caudal from the center <strong>of</strong> the C3-7<br />
cord from each group. Five millimeters <strong>of</strong> the gastric
A B<br />
C<br />
Song XH et al . Neck-stomach syndrome 2577<br />
Figure 1 Expression <strong>of</strong> c-Fos in the cervical cord. A: Control group; B: Model<br />
group at 3 mo; C: Model group at 5 mo. There were only a few c-Fos expression<br />
in the cervical cord <strong>of</strong> the control group, but an increased c-Fos expression in the<br />
model groups at 3 mo and 5 mo after the operation.<br />
Table 1 c-Fos-positive neurons in the cervical dorsal horn in the<br />
two different groups (%, mean ± SD)<br />
Groups Number <strong>of</strong> c-Fos-positive neurons<br />
3 mo 5 mo<br />
Control group 1.25 ± 0.25 1.98 ± 0.60<br />
Model group 11.20 ± 2.26 27.68 ± 4.36<br />
antrum including the anterior and posterior wall was<br />
then extracted longitudinally and opened at the greater<br />
curvature, thoroughly rinsed by 0.15 mol/L PBS. The<br />
cord and gastric antrum tissues were resuspended in a lysis<br />
buffer (Cell Signaling Technology) and homogenized in<br />
a homogenizer on ice. Tissue homogenate samples were<br />
centrifuged at 1000 r/min for 10 min at 4℃, and the<br />
supernatants were stored at -30℃. Protein concentrations<br />
in the cell lysates were determined using the Bio-Rad<br />
protein assay (Bio-Rad, Richmond, CA, USA) as following<br />
manufacturer’s instructions. For Western blot analysis,<br />
20 μL <strong>of</strong> each suspension sample was separated on<br />
120 g/L sodium dodecyl sulphate-polyacrylamide gel<br />
electrophoresis and the proteins were transferred onto<br />
nitrocellulose membranes. Blots were blocked with 50 g/L<br />
non-fat dry milk in Tris-buffered saline (TBS) for 1 h<br />
at room temperature and then the membranes were<br />
incubated with 1:200 diluted monoclonal rabbit anti-rat<br />
antibodies against IL-1β (Sigma-Aldrich) or caspase-3<br />
(Sigma-Aldrich) overnight at 4℃. The membranes were<br />
then processed with horseradish peroxidase-conjugated<br />
goat anti-rabbit secondary antibody (1:500; Sigma-<br />
Aldrich). Immunoreactive bands were detected by ECL<br />
chemiluminescence kit (Amersham, USA).<br />
Statistical analysis<br />
Data were expressed as mean ± SD. Statistical analysis<br />
A B C<br />
Figure 2 Expression <strong>of</strong> c-Fos in the gastric antrum. A: Control group; B: Model<br />
group; C: Enlarged figure <strong>of</strong> the model group. Neurons were defined as c-Fospositive<br />
when the nucleus was stained with intensity clearly above the faint<br />
background stain, whereas neurons were defined as c-Fos-negative when the<br />
nucleus was either not stained at all or stained with intensity close to background<br />
stain.<br />
Table 2 c-Fos-positive neurons in the antral ganglia between<br />
the two different groups (%, mean ± SD)<br />
Groups Number <strong>of</strong> c-Fos-positive neurons<br />
3 mo 5 mo<br />
Control group 2.4 ± 0.6 3.2 ± 0.8<br />
Model group 11.3 ± 2.3 29.3 ± 4.6<br />
was performed using one-way ANOVA. The significant<br />
difference between pairs <strong>of</strong> groups was tested by post-hoc<br />
analysis. P < 0.05 was considered statistically significant.<br />
RESULTS<br />
c-Fos expression in the cervical cord<br />
There were only a few c-Fos-expressing neurons in the<br />
cervical cord <strong>of</strong> the control group. However, an increased<br />
c-Fos expression was observed in the model groups at<br />
3 mo and 5 mo after the operation (Figure 1, Table 1).<br />
There was no significant spontaneous c-Fos expression<br />
in the spinal cord in the control group at 3 mo and 5 mo<br />
after sham operation, whereas there was a significant<br />
increase in c-Fos expression in the model group rats. More<br />
importantly, there was a significant difference in c-Fos<br />
expression between the model group rats at 3 mo and<br />
those at 5 mo after the operation (P < 0.05).<br />
Expression <strong>of</strong> c-Fos in the gastric antrum<br />
The number <strong>of</strong> c-Fos-positive neurons in the gastric<br />
antrum was expressed as a percentage <strong>of</strong> the total number<br />
<strong>of</strong> neurons per ganglion as assessed by cuprolinic blue<br />
counterstaining. There was no significant spontaneous c-Fos<br />
expression in the antrum in the control group at 3 and 5 mo<br />
after the sham operation; whereas there was a significant<br />
increase in c-Fos expression in the model groups. More<br />
importantly, a significant difference in c-Fos expression<br />
was observed between the model group rats at 3 mo and<br />
those at 5 mo after the operation (P < 0.05) (Table 2). c-Fos<br />
expression was seen in Figure 2.<br />
Caspase-3 and IL-1β expression in the cervical cord and<br />
stomach<br />
The caspase-3 and IL-1β expression in the cervical cord<br />
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2578 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
A B C D<br />
E F G H<br />
Figure 3 Expression <strong>of</strong> caspase-3 and IL-1β in the cervical cord and stomach. A: An increased immunoreactivity and positive neurons <strong>of</strong> IL-1β in model group; B: Negative<br />
expression <strong>of</strong> IL-1β in control group; C: An increased expression <strong>of</strong> caspase-3 in model group; D: Negative immunoreactivity <strong>of</strong> caspase-3 in control group; E: Positive<br />
expression <strong>of</strong> IL-1β in the stomach <strong>of</strong> model group; F: Negative expression <strong>of</strong> IL-1β in the stomach <strong>of</strong> control group; G: An increased expression <strong>of</strong> caspase-3 in the<br />
stomach <strong>of</strong> model group; H: Negative immunoreactivity <strong>of</strong> caspase-3 in the stomach <strong>of</strong> control group.<br />
Table 3 Cells positive for caspase-3 and IL-1β in the stomach<br />
<strong>of</strong> rats with cervical spondylosis mean ± SD<br />
Groups Caspase-3-positive cells IL-1β-positive cells<br />
3-mo group 33.83 ± 3.71 42.06 ± 2.95<br />
5-mo group 36.32 ± 4.01 45.91 ± 3.98<br />
There was no significant difference between the controls, but a significant<br />
difference between the control groups and the model groups at 3 mo and 5<br />
mo after the operation (P < 0.01).<br />
and stomach was examined by immunohistochemistry<br />
(Figure 3, Tables 3 and 4). Buffy spots or particles in cells<br />
were regarded as positive expression <strong>of</strong> caspase-3 and IL-<br />
1β. The positive cells were increased both in the cervical<br />
cord and stomach <strong>of</strong> model group rats. There was no<br />
significant expression in the control group at 3 mo and<br />
5 mo after the sham operation. However, there was a<br />
significant increase both in the cervical cord and stomach<br />
<strong>of</strong> the model group rats. More importantly, there was a<br />
significant difference in caspase-3 and IL-1β expression<br />
both in the cervical cord and stomach between the model<br />
group rats at 3 mo and those at 5 mo after the operation (P<br />
< 0.05) (Tables 3 and 4).<br />
Western blot analysis <strong>of</strong> caspase-3 and IL-1β expression<br />
Western blot analysis showed time-dependent changes<br />
<strong>of</strong> caspase-3 and IL-1β protein in the cervical cord <strong>of</strong><br />
rats with cervical spondylosis (Figure 4). Densitometry<br />
readings <strong>of</strong> gel bands were expressed as arbitrary units.<br />
www.wjgnet.com<br />
Table 4 Cells positive for caspase-3 and IL-1β in the spinal cord<br />
<strong>of</strong> rats with cervical spondylosis mean ± SD<br />
Group Caspase-3-positive cells IL-1β-positive cells<br />
3-mo control group 2.01 ± 1.36 1.98 ± 2.01<br />
3-mo model group 13.23 ± 3.21 26.56 ± 2.65<br />
5-mo control group 3.26 ± 3.02 2.31 ± 2.48<br />
5-mo model group 26.32 ± 4.01 32.01 ± 2.98<br />
There was no significant difference between the controls, but a significant<br />
difference between the model groups at 3 and 5 mo after the operation<br />
(P < 0.05) and also the control groups vs the model groups at 3 mo and 5 mo,<br />
respectively (P < 0.05).<br />
There was no significant expression <strong>of</strong> caspase-3 and IL-<br />
1β protein in the control group at 3 and 5 mo after sham<br />
operation, however, there was a significant expression<br />
in the model group rats. More importantly, there was a<br />
significant difference expression between model group rats<br />
at 3 and those at 5 mo after the operation (P < 0.05).<br />
DISCUSSION<br />
The definition <strong>of</strong> neck-stomach symptoms is gastrointestinal<br />
disorders resulting from cervical spondylosis.<br />
The sympathetic fibers are distributed in the periphery<br />
<strong>of</strong> the dorsal root ganglion (DRG). The adventive nerves<br />
interact with the neurons <strong>of</strong> the DRG by a non-synaptic<br />
signaling [20,21] . The sympathetic fibers are distribution in<br />
the Luschka, articular capsule, cervical facet joints, cervical<br />
posterior longitudinal ligaments, posterior annulus fibrosus
A<br />
B<br />
C<br />
D<br />
Song XH et al . Neck-stomach syndrome 2579<br />
Control 3 mo Control 5 mo Control 3 mo Control 5 mo<br />
Figure 4 Expression <strong>of</strong> caspase-3 and IL-1β protein detected by Western blot.<br />
A: Caspase-3 expression in the cord at 3 mo and 5 mo in different groups; B: IL-<br />
1β expression in the cord at 3 mo and 5 mo in different groups; C: Caspase-3<br />
expression in the gastric antrum at 3 mo and 5 mo in different groups; D: IL-1β<br />
expression in the gastric antrum at 3 mo and 5 mo in different groups.<br />
and vertebral artery. Parts <strong>of</strong> cervical nerve roots connect<br />
with superior cervical ganglion via postganglionic fibres.<br />
When the sympathetic fibers are irritated, the clinical<br />
syndromes result from the spinal and brain-spinal reflex<br />
pathways [22] .<br />
The mechanism <strong>of</strong> neck-stomach syndrome is that<br />
when the sympathetic nerve is irritated by nerve roots,<br />
degenerated disc and facet joints disorders due to<br />
osteophytes, cervical muscle overexertion and/or injury,<br />
the irritation reaches to the brain cortex by nerve reflex<br />
and produces a higher or lower sympathetic irritability, and<br />
then results in multiple dysfunctions <strong>of</strong> the neck, upper<br />
limbs, cardiac and gastrointestinal reflexes, etc.<br />
c-Fos as the third messenger provides a reliable and<br />
shortcut method to study the mechanism <strong>of</strong> functional<br />
gastrointestinal diseases [5] . Gilby et al [23] reported c-Fos, as a<br />
third messenger, regulates target gene expression and plays<br />
a key role in nerve system signal transmission. A study<br />
showed that expression <strong>of</strong> c-Fos proto-oncogene in fetus<br />
cerebral nerve cell cultured in vitro was regulated specially<br />
by IL-1β in time course [24] .<br />
Many studies have shown that c-Fos expression is<br />
related to functional gastrointestinal diseases, such as c-Fos<br />
abnormal expression in intestinal myenteric plexus and<br />
CNS in inflammatory bowel disease (IBD), irritable bowel<br />
syndrome (IBS) and Crohn’s disease [25,26] . Enteric nervous<br />
system (ENS) owns a strong biological compatibility,<br />
and c-Fos may be a good index <strong>of</strong> ENS to short and/or<br />
chronic gastrointestinal irritation [25-27] .<br />
In our study, Western blot analysis showed timedependent<br />
changes <strong>of</strong> caspase-3 and IL-1β protein in<br />
the cervical cord and gastric antrum <strong>of</strong> rats with cervical<br />
spondylosis. We observed an increased c-Fos, caspase-3<br />
and IL-1β expression in model group rats at 3 and 5<br />
mo after operation by immunohistochemistry staining.<br />
Interestingly, we found a significant difference in c-Fos,<br />
caspase-3 and IL-1β expression between the model<br />
group rats at 3 mo and those at 5 mo after the operation.<br />
Expression <strong>of</strong> c-Fos, caspase-3 and IL-1β in the gastric<br />
antrum were dramatically associated with that in the spinal<br />
cord <strong>of</strong> rats with cervical spondylosis, suggesting that<br />
the gastrointestinal function may be affected by cervical<br />
spondylosis and that the c-Fos expression may be regulated<br />
by IL-1β. Further studies need to validate this hypothesis.<br />
Because <strong>of</strong> the accumulated knowledge <strong>of</strong> diseases,<br />
there is a rapid transition in modern medical sciences from<br />
the simple biological pattern based on unity biology to<br />
the biology-psychology-society pattern. The traditional<br />
“functional gastrointestinal disorders” in the past are<br />
now known as multiple physical and patho-physiological<br />
diseases involving gastrointestinal motility, gut sensitivity,<br />
brain-intestine axis, brain-intestine peptides, societyphysiology<br />
factors and stress. Especially, the conception<br />
<strong>of</strong> brain-intestine axis and neurogastroenterology has been<br />
put forward, which indicates that the alimentary canal is<br />
controlled by both motor and sensory nerves. When a<br />
nerve is injured, the lesion will impact on both the sense<br />
and motion realms. Even though the lesion is limited in<br />
only one realm, the change will result in the change <strong>of</strong><br />
other region’s function [28,29] . Theoretically, only when the<br />
gastrointestinal tract and CNS are integratively investigated,<br />
can the multiple physical and pathophysiological diseases<br />
be further understood.<br />
The previous studies had proven mechanisms <strong>of</strong> FD<br />
and IBS were associated with CNS [28,30] . In the present<br />
study, we found the same results and believe that there are<br />
relationships between the neck and stomach.<br />
ACKNOWLEDGMENTS<br />
We are grateful to Dr. Michael L Harding for revising the<br />
manuscript.<br />
REFERENCES<br />
1 Jiang GL, Li JJ, Xia XY, Xiao L. A clinical observation on<br />
the treatment <strong>of</strong> neck-stomach syndrome by three-step<br />
acupuncture and cupping. Xin Zhongyi 2002; 34: 49-50<br />
2 Bullitt E. Induction <strong>of</strong> c-fos-like protein within the lumbar<br />
spinal cord and thalamus <strong>of</strong> the rat following peripheral<br />
stimulation. Brain Res 1989; 493: 391-397<br />
3 Presley RW, Menetrey D, Levine JD, Basbaum AI. Systemic<br />
morphine suppresses noxious stimulus-evoked Fos proteinlike<br />
immunoreactivity in the rat spinal cord. J Neurosci 1990;<br />
10: 323-335<br />
4 Kominato Y, Tachibana T, Dai Y, Tsujino H, Maruo S, Noguchi<br />
K. Changes in phosphorylation <strong>of</strong> ERK and Fos expression in<br />
dorsal horn neurons following noxious stimulation in a rat<br />
model <strong>of</strong> neuritis <strong>of</strong> the nerve root. Brain Res 2003; 967: 89-97<br />
5 Zhang FF, Mo JZ. Application study on c-fos import<br />
signal induced by gastrointestinal irritation. Guowai Yixue<br />
Xiaohuaxijibing Fence 2004, 24: 35-37<br />
6 Song PS, Kong KM, Niu CY, Qi WL, Wu LF, Wang XJ, Han<br />
W, Huang K, Chen ZF. Expression <strong>of</strong> c-fos in gastric myenteric<br />
plexus and spinal cord <strong>of</strong> rats with cervical spondylosis. <strong>World</strong><br />
J Gastroenterol 2005; 11: 529-533<br />
7 Li M, Ona VO, Chen M, Kaul M, Tenneti L, Zhang X, Stieg PE,<br />
Lipton SA, Friedlander RM. Functional role and therapeutic<br />
implications <strong>of</strong> neuronal caspase-1 and -3 in a mouse model <strong>of</strong><br />
traumatic spinal cord injury. Neuroscience 2000; 99: 333-342<br />
8 Springer JE, Azbill RD, Knapp PE. Activation <strong>of</strong> the caspase-3<br />
apoptotic cascade in traumatic spinal cord injury. Nat Med<br />
1999; 5: 943-946<br />
9 Nesic O, Xu GY, McAdoo D, High KW, Hulsebosch C, Perez-<br />
Pol R. IL-1 receptor antagonist prevents apoptosis and caspase-3<br />
activation after spinal cord injury. J Neurotrauma 2001; <strong>18</strong>:<br />
947-956<br />
10 Lynch AM, Lynch MA. The age-related increase in IL-1 type<br />
www.wjgnet.com
2580 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
I receptor in rat hippocampus is coupled with an increase in<br />
caspase-3 activation. Eur J Neurosci 2002; 15: 1779-1788<br />
11 Fankhauser C, Friedlander RM, Gagliardini V. Prevention<br />
<strong>of</strong> nuclear localization <strong>of</strong> activated caspases correlates with<br />
inhibition <strong>of</strong> apoptosis. Apoptosis 2000; 5: 117-132<br />
12 Ehrlich LC, Peterson PK, Hu S. Interleukin (IL)-1beta-mediated<br />
apoptosis <strong>of</strong> human astrocytes. Neuroreport 1999; 10: <strong>18</strong>49-<strong>18</strong>52<br />
13 Takahashi JL, Giuliani F, Power C, Imai Y, Yong VW.<br />
Interleukin-1beta promotes oligodendrocyte death through<br />
glutamate excitotoxicity. Ann Neurol 2003; 53: 588-595<br />
14 Song PS, Kong KM, Qi WL, Wang XJ, Han W, Huang K, Chen<br />
ZF. Compare study on the models <strong>of</strong> cervical spondylosis <strong>of</strong><br />
muscle imbalance and posterior column instability in rats.<br />
Shantou Daxue Yixueyuan Xuebao 2004; 17: 71-72<br />
15 Song PS, Kong KM, Qi WL, Wang XJ, Han W, Huang K. IL-β<br />
Expression in Spinal Cord <strong>of</strong> Rat with Cervical Spondylosis<br />
and Its Significance. Zhongyi Zhenggu 2006; <strong>18</strong>: 83-85<br />
16 Lee YB, Yune TY, Baik SY, Shin YH, Du S, Rhim H, Lee EB,<br />
Kim YC, Shin ML, Markelonis GJ, Oh TH. Role <strong>of</strong> tumor<br />
necrosis factor-alpha in neuronal and glial apoptosis after<br />
spinal cord injury. Exp Neurol 2000; 166: 190-195<br />
17 Tomlinson A, Appleton I, Moore AR, Gilroy DW, Willis D,<br />
Mitchell JA, Willoughby DA. Cyclo-oxygenase and nitric<br />
oxide synthase is<strong>of</strong>orms in rat carrageenin-induced pleurisy.<br />
Br J Pharmacol 1994; 113: 693-698<br />
<strong>18</strong> Holst MC, Powley TL. Cuprolinic blue (quinolinic phthalocyanine)<br />
counterstaining <strong>of</strong> enteric neurons for peroxidase<br />
immunocytochemistry. J Neurosci Methods 1995; 62: 121-127<br />
19 Hsu SM, Raine L, Fanger H. The use <strong>of</strong> antiavidin antibody<br />
and avidin-biotin-peroxidase complex in immunoperoxidase<br />
technics. Am J Clin Pathol 1981; 75: 816-821<br />
20 Kummer W, Gibbins IL, Stefan P, Kapoor V. Catecholamines<br />
and catecholamine-synthesizing enzymes in guinea-pig<br />
www.wjgnet.com<br />
sensory ganglia. Cell Tissue Res 1990; 261: 595-606<br />
21 Utzschneider D, Kocsis J, Devor M. Mutual excitation among<br />
dorsal root ganglion neurons in the rat. Neurosci Lett 1992; 146:<br />
53-56<br />
22 Yu ZS, Ma QJ, Liu ZJ. The Clinical Manifestation, Diagnosis<br />
and Differential Diagnosis <strong>of</strong> Sympathetic Cervical Spondylosis.<br />
Zhongguo Quanke Yixue 2001; 4: 512-513<br />
23 Gilby KL, Armstrong JN, Currie RW, Robertson HA. The<br />
effects <strong>of</strong> hypoxia-ischemia on expression <strong>of</strong> c-Fos, c-Jun and<br />
Hsp70 in the young rat hippocampus. Brain Res Mol Brain Res<br />
1997; 48: 87-96<br />
24 Ying XQ, Wei J, Li LY, Pang ZL. IL-6, IL-1β and TNFα induce<br />
the expression <strong>of</strong> c-fos and c-jun in human fetal cerebral<br />
neurons. Zhongguo Mianyixue Zazhi 2000; 16: 669-671<br />
25 Traub RJ, Murphy A. Colonic inflammation induces fos<br />
expression in the thoracolumbar spinal cord increasing activity<br />
in the spinoparabrachial pathway. Pain 2002; 95: 93-102<br />
26 Lu Y, Westlund KN. Effects <strong>of</strong> bacl<strong>of</strong>en on colon inflammationinduced<br />
Fos, CGRP and SP expression in spinal cord and<br />
brainstem. Brain Res 2001; 889: 1<strong>18</strong>-130<br />
27 Sharkey KA, Kroese AB. Consequences <strong>of</strong> intestinal<br />
inflammation on the enteric nervous system: neuronal activation<br />
induced by inflammatory mediators. Anat Rec 2001; 262: 79-90<br />
28 Luo JY, Niu CY. New conception <strong>of</strong> functional gastrointestinal<br />
disorders and disorders <strong>of</strong> gastrointestinal motility. Zhonghua<br />
Xiaohua Zazhi 2002; 22: 554-558<br />
29 Dai F, Gong J, Zhang R, Luo JY, Zhu YL, Wang XQ.<br />
Assessment <strong>of</strong> duodenogastric reflux by combined continuous<br />
intragastric pH and bilirubin monitoring. <strong>World</strong> J Gastroenterol<br />
2002; 8: 382-384<br />
30 Zhou L. Physiological and pathophisiological mechanism <strong>of</strong><br />
gastrointestinal functional and motional disorders. Zhongguo<br />
Shiyong Neike Zazhi 2001; 21: 577-579<br />
S- Editor Liu Y L- Editor Kumar M E- Editor Che YB
Percentage<br />
Caner V et al . Virulence genes in H pylori strains 2583<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
(89.1%) isolates were the type s1 and 38/46 (82.6%)<br />
isolates were the type m2. The vacA s1m2 genotype was<br />
the predominant subtype, being found in 63.3% <strong>of</strong> the<br />
isolates in patients with CG and 68.7% <strong>of</strong> those with DU.<br />
No vacA s2m1 genotype was determined in this study<br />
(Figure 1). No correlation between the vacA genotype<br />
and both gastroduodenal pathologies was observed. The<br />
presence <strong>of</strong> the vacA s1m2 genotype in combination with<br />
cagA were 73.3% and 68.7% <strong>of</strong> the isolates in CG and DU,<br />
respectively.<br />
In this study, the iceA1 allele was detected in 45.7%<br />
(21/46) <strong>of</strong> the H pylori isolates, and the iceA2 allele was<br />
detected in 54.3% (25) <strong>of</strong> the isolates. The iceA1 allele was<br />
significantly associated with DU (68.8%, P < 0.05) while<br />
there was a significant relationship between iceA2 allele and<br />
CG (66.6%, P < 0.05) (Figure 2).<br />
DISCUSSION<br />
Chronic gastritis<br />
Duodenal ulcer disease<br />
cagA vacA vacA vacA<br />
s1m1 s1m2 s2m2<br />
Figure 1 Percentage <strong>of</strong> distrubitions <strong>of</strong> cagA gene and vacA alleles in chronic<br />
gastritis and duodenal ulcer disease.<br />
Several epidemiological studies have been reported the<br />
influence <strong>of</strong> particular virulence genes (especially cagA,<br />
vacA, and iceA) on clinical outcome <strong>of</strong> H pylori infection in<br />
different geographic regions [4-8] . This study was designed<br />
to characterize and to compare the genotype pr<strong>of</strong>iles <strong>of</strong><br />
H pylori strains isolated from patients with chronic gastritis<br />
and duodenal ulcer in western part <strong>of</strong> Turkey.<br />
In this study, the prevalence <strong>of</strong> cagA gene was 93.3%<br />
and 93.75 in H pylori isolates in patients with CG and<br />
DU, respectively. The result obtained from the isolates in<br />
the patients with DU is in aggrement with other studies<br />
carried out in patients with DU in Turkey (85%-89%) [8,<strong>18</strong>] .<br />
However, the cagA prevalence in total is similar to those<br />
reported in Asia [6,12,21] and Ireland [22] but higher than those<br />
in Western countries [5,23,24] . Interestingly, the high prevalence<br />
<strong>of</strong> cagA (93.3%) in isolates <strong>of</strong> patients with CG was<br />
observed. The presence <strong>of</strong> cagA is known as a predictive<br />
marker for cag-PAI. Although intact cag-PAI was associated<br />
with the development <strong>of</strong> gastroduodenal pathology [25] it<br />
was also recenty reported that this island was not intact<br />
in many strains across the world [26] . Therefore, the high<br />
prevalence <strong>of</strong> cagA in CG could not be explained precisely,<br />
a possible reason to explain this phenomenon is that the<br />
cagA positive strains with nonintact PAI might likely carry<br />
Percentage<br />
80<br />
60<br />
40<br />
20<br />
0<br />
iceA1 iceA2<br />
Chronic gastritis<br />
Duodenal ulcer disease<br />
Figure 2 iceA alleles show specificity for chronic gastritis and duodenal ulcer<br />
disease.<br />
deleted or nonfunctional virulence genes [25] .<br />
The vacA gene was detected in all strains. The vacA<br />
s1m2 genotype predominant irrespective <strong>of</strong> the clinical<br />
outcome was also predominant in strains from Western<br />
countries including Turkey [4,<strong>18</strong>,22,27] . Aydin F et al [19] reported<br />
the vacA s1m1 genotype was the common vacA genotype<br />
in Black sea region located in Asian part <strong>of</strong> Turkey. The<br />
prevalence <strong>of</strong> vacA s1m1 genotype in our study was 6.6%<br />
and 25% <strong>of</strong> the strains in patients with CG and DU,<br />
respectively. The assesment <strong>of</strong> vacA gene mosaicism found<br />
only three out <strong>of</strong> the four possible combinations, the<br />
s2m1 mosaicism being never detected in our series, which<br />
was typically observed in strains from Western country<br />
including Turkey [<strong>18</strong>,19,22,24] . In this study, the cagA vacA s1m2<br />
genotype was predominat genotype, and there was no<br />
significant relationship between both <strong>of</strong> the pathologies,<br />
indicating that the genotype was common virulence factors<br />
<strong>of</strong> H pylori.<br />
Although the function <strong>of</strong> iceA gene is not clear, it<br />
is known that the expression <strong>of</strong> the gene is induced by<br />
contact between H pylori and the epithelial cells <strong>of</strong> the<br />
stomach [17] . The previous studies focused on the iceA<br />
genotyping in Turkey was limited. One <strong>of</strong> them reported<br />
that there was no significant association between the<br />
iceA genotype and clinical otcome <strong>of</strong> H pylori infection [20]<br />
while the other was found the iceA allele was significantly<br />
higher among patients with gastric cancer when compared<br />
to patients with non-ulcer dyspepsia [<strong>18</strong>] . In present study,<br />
most H pylori strains (66.6%) isolated from patients with<br />
chronic gastritis had iceA2 allele while iceA1 allele was<br />
predominant in those with duodenal ulcer disease (68.8%).<br />
This difference was statistically significant. In terms <strong>of</strong> the<br />
association <strong>of</strong> the iceA1 allele to DU, there is an aggrement<br />
with the previous studies carried out in the USA [6] ,<br />
China [28] , and Netherland [5] but in contrast to the results<br />
reported from Japan [6] . The high prevalence <strong>of</strong> the iceA2<br />
allele in patients with CG was also observed in the USA [6] .<br />
Such differences the discrepant results between the iceA<br />
alleles and the clinical outcome <strong>of</strong> H pylori infection could<br />
be explained by the genetic heterogenity or to differences<br />
in the geographic locations as were previously reported for<br />
the other virulence genes [29,30] .<br />
www.wjgnet.com
2584 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
In summary, the prevalent circulating genotypes in CG<br />
and DU in western part <strong>of</strong> Turkey were cagA vacA s1m2<br />
iceA2 and cagA vacA s1m2 iceA1 genotype, respectively. It<br />
was also found that cagA vacAs1m2 genotype seems to be<br />
common virulence factors in both chronic gastritis and<br />
duodenal ulcer disease while iceA alleles show specificity<br />
for gastroduodenal ulcer disease. To understand the<br />
pathogenesis <strong>of</strong> the infection, the population genetics<br />
<strong>of</strong> H pylori together with host response including genetic<br />
predisposition and immune response, and environmental<br />
factors should also be considered.<br />
ACKNOWLEDGMENTS<br />
The authors wish to acknowledge the financial support<br />
provided by a grant from the State Planning Organization<br />
in the Prime Ministry <strong>of</strong> Republic <strong>of</strong> Turkey (DPT-<br />
2003K120950). The authors also thank Dr. Nilay Sen Turk<br />
for statistical advace and Dario Papi for designing <strong>of</strong> all<br />
oligonucleotide primers. This work was presented in part<br />
at the XXXI.th Turkish Microbiology Congress, Kusadasi-<br />
Aydin, Turkey, 19-23 September 2004.<br />
REFERENCES<br />
1 Lambert JR, Lin SK, Aranda-Michel J. Helicobacter pylori. Scand<br />
J Gastroenterol Suppl 1995; 208: 33-46<br />
2 Blaser MJ, Atherton JC. Helicobacter pylori persistence: biology<br />
and disease. J Clin Invest 2004; 113: 321-333<br />
3 Peek RM Jr, Blaser MJ. Helicobacter pylori and gastrointestinal<br />
tract adenocarcinomas. Nat Rev Cancer 2002; 2: 28-37<br />
4 Miehlke S, Yu J, Schuppler M, Frings C, Kirsch C, Negraszus N,<br />
Morgner A, Stolte M, Ehninger G, Bayerdorffer E. Helicobacter<br />
pylori vacA, iceA, and cagA status and pattern <strong>of</strong> gastritis in<br />
patients with malignant and benign gastroduodenal disease.<br />
Am J Gastroenterol 2001; 96: 1008-1013<br />
5 van Doorn LJ, Figueiredo C, Sanna R, Plaisier A, Schneeberger<br />
P, de Boer W, Quint W. Clinical relevance <strong>of</strong> the cagA, vacA,<br />
and iceA status <strong>of</strong> Helicobacter pylori. <strong>Gastroenterology</strong> 1998; 115:<br />
58-66<br />
6 Yamaoka Y, Kodama T, Gutierrez O, Kim JG, Kashima K,<br />
Graham DY. Relationship between Helicobacter pylori iceA,<br />
cagA, and vacA status and clinical outcome: studies in four<br />
different countries. J Clin Microbiol 1999; 37: 2274-2279<br />
7 Li L, Graham DY, Gutierrez O, Kim JG, Genta RM, El-Zimaity<br />
HM, Go MF. Genomic fingerprinting and genotyping <strong>of</strong><br />
Helicobacter pylori strains from patients with duodenal ulcer or<br />
gastric cancer from different geographic regions. Dig Dis Sci<br />
2002; 47: 2512-25<strong>18</strong><br />
8 Saribasak H, Salih BA, Yamaoka Y, Sander E. Analysis <strong>of</strong><br />
Helicobacter pylori genotypes and correlation with clinical<br />
outcome in Turkey. J Clin Microbiol 2004; 42: 1648-1651<br />
9 Censini S, Lange C, Xiang Z, Crabtree JE, Ghiara P,<br />
Borodovsky M, Rappuoli R, Covacci A. cag, a pathogenicity<br />
island <strong>of</strong> Helicobacter pylori, encodes type I-specific and<br />
disease-associated virulence factors. Proc Natl Acad Sci USA<br />
1996; 93: 14648-14653<br />
10 Odenbreit S, Puls J, Sedlmaier B, Gerland E, Fischer W, Haas R.<br />
Translocation <strong>of</strong> Helicobacter pylori CagA into gastric epithelial<br />
cells by type IV secretion. Science 2000; 287: 1497-1500<br />
11 Zarrilli R, Ricci V, Romano M. Molecular response <strong>of</strong> gastric<br />
epithelial cells to Helicobacter pylori-induced cell damage. Cell<br />
Microbiol 1999; 1: 93-99<br />
12 Pan ZJ, van der Hulst RW, Feller M, Xiao SD, Tytgat GN,<br />
Dankert J, van der Ende A. Equally high prevalences <strong>of</strong><br />
infection with cagA-positive Helicobacter pylori in Chinese<br />
patients with peptic ulcer disease and those with chronic<br />
www.wjgnet.com<br />
gastritis-associated dyspepsia. J Clin Microbiol 1997; 35:<br />
1344-1347<br />
13 Maeda S, Ogura K, Yoshida H, Kanai F, Ikenoue T, Kato N,<br />
Shiratori Y, Omata M. Major virulence factors, VacA and<br />
CagA, are commonly positive in Helicobacter pylori isolates in<br />
Japan. Gut 1998; 42: 338-343<br />
14 Cover TL, Blaser MJ. Purification and characterization <strong>of</strong> the<br />
vacuolating toxin from Helicobacter pylori. J Biol Chem 1992;<br />
267: 10570-10575<br />
15 Atherton JC, Cao P, Peek RM Jr, Tummuru MK, Blaser MJ,<br />
Cover TL. Mosaicism in vacuolating cytotoxin alleles <strong>of</strong><br />
Helicobacter pylori. Association <strong>of</strong> specific vacA types with<br />
cytotoxin production and peptic ulceration. J Biol Chem 1995;<br />
270: 17771-17777<br />
16 Atherton JC, Peek RM Jr, Tham KT, Cover TL, Blaser MJ.<br />
Clinical and pathological importance <strong>of</strong> heterogeneity in<br />
vacA, the vacuolating cytotoxin gene <strong>of</strong> Helicobacter pylori.<br />
<strong>Gastroenterology</strong> 1997; 112: 92-99<br />
17 Peek RM Jr, Thompson SA, Donahue JP, Tham KT, Atherton<br />
JC, Blaser MJ, Miller GG. Adherence to gastric epithelial cells<br />
induces expression <strong>of</strong> a Helicobacter pylori gene, iceA, that is<br />
associated with clinical outcome. Proc Assoc Am Physicians<br />
1998; 110: 531-544<br />
<strong>18</strong> Erzin Y, Koksal V, Altun S, Dobrucali A, Aslan M, Erdamar<br />
S, Dirican A, Kocazeybek B. Prevalence <strong>of</strong> Helicobacter pylori<br />
vacA, cagA, cagE, iceA, babA2 genotypes and correlation<br />
with clinical outcome in Turkish patients with dyspepsia.<br />
Helicobacter 2006; 11: 574-580<br />
19 Aydin F, Kaklikkaya N, Ozgur O, Cubukcu K, Kilic AO,<br />
Tosun I, Erturk M. Distribution <strong>of</strong> vacA alleles and cagA<br />
status <strong>of</strong> Helicobacter pylori in peptic ulcer disease and nonulcer<br />
dyspepsia. Clin Microbiol Infect 2004; 10: 1102-1104<br />
20 Baglan PH, Bozdayi G, Ozkan M, Ahmed K, Bozdayi AM,<br />
Ozden A. Clarithromycin resistance prevalence and Icea gene<br />
status in Helicobacter Pylori clinical isolates in Turkish patients<br />
with duodenal ulcer and functional dyspepsia. J Microbiol<br />
2006; 44: 409-416<br />
21 Zhou W, Yamazaki S, Yamakawa A, Ohtani M, Ito Y, Keida<br />
Y, Higashi H, Hatakeyama M, Si J, Azuma T. The diversity <strong>of</strong><br />
vacA and cagA genes <strong>of</strong> Helicobacter pylori in East Asia. FEMS<br />
Immunol Med Microbiol 2004; 40: 81-87<br />
22 Ryan KA, Moran AP, Hynes SO, Smith T, Hyde D, O'Morain<br />
CA, Maher M. Genotyping <strong>of</strong> cagA and vacA, Lewis antigen<br />
status, and analysis <strong>of</strong> the poly-(C) tract in the alpha(1,3)fucosyltransferase<br />
gene <strong>of</strong> Irish Helicobacter pylori isolates.<br />
FEMS Immunol Med Microbiol 2000; 28: 113-120<br />
23 Rudi J, Kolb C, Maiwald M, Kuck D, Sieg A, Galle PR,<br />
Stremmel W. Diversity <strong>of</strong> Helicobacter pylori vacA and cagA<br />
genes and relationship to VacA and CagA protein expression,<br />
cytotoxin production, and associated diseases. J Clin Microbiol<br />
1998; 36: 944-948<br />
24 Andreson H, Loivukene K, Sillakivi T, Maaroos HI, Ustav<br />
M, Peetsalu A, Mikelsaar M. Association <strong>of</strong> cagA and vacA<br />
genotypes <strong>of</strong> Helicobacter pylori with gastric diseases in Estonia.<br />
J Clin Microbiol 2002; 40: 298-300<br />
25 Nilsson C, Sillen A, Eriksson L, Strand ML, Enroth H,<br />
Normark S, Falk P, Engstrand L. Correlation between cag<br />
pathogenicity island composition and Helicobacter pyloriassociated<br />
gastroduodenal disease. Infect Immun 2003; 71:<br />
6573-6581<br />
26 Kauser F, Khan AA, Hussain MA, Carroll IM, Ahmad N,<br />
Tiwari S, Shouche Y, Das B, Alam M, Ali SM, Habibullah<br />
CM, Sierra R, Megraud F, Sechi LA, Ahmed N. The cag<br />
pathogenicity island <strong>of</strong> Helicobacter pylori is disrupted in the<br />
majority <strong>of</strong> patient isolates from different human populations.<br />
J Clin Microbiol 2004; 42: 5302-5308<br />
27 Van Doorn LJ, Figueiredo C, Megraud F, Pena S, Midolo P,<br />
Queiroz DM, Carneiro F, Vanderborght B, Pegado MD, Sanna<br />
R, De Boer W, Schneeberger PM, Correa P, Ng EK, Atherton J,<br />
Blaser MJ, Quint WG. Geographic distribution <strong>of</strong> vacA allelic<br />
types <strong>of</strong> Helicobacter pylori. <strong>Gastroenterology</strong> 1999; 116: 823-830<br />
28 Lin HJ, Perng CL, Lo WC, Wu CW, Tseng GY, Li AF, Sun IC,
Caner V et al . Virulence genes in H pylori strains 2585<br />
Ou YH. Helicobacter pylori cagA, iceA and vacA genotypes in<br />
patients with gastric cancer in Taiwan. <strong>World</strong> J Gastroenterol<br />
2004; 10: 2493-2497<br />
29 Covacci A, Telford JL, Del Giudice G, Parsonnet J, Rappuoli<br />
R. Helicobacter pylori virulence and genetic geography. Science<br />
1999; 284: 1328-1333<br />
30 Yamaoka Y, Orito E, Mizokami M, Gutierrez O, Saitou N,<br />
Kodama T, Osato MS, Kim JG, Ramirez FC, Mahachai V,<br />
Graham DY. Helicobacter pylori in North and South America<br />
before Columbus. FEBS Lett 2002; 517: <strong>18</strong>0-<strong>18</strong>4<br />
S- Editor Liu Y L- Editor Alpini GD E- Editor Liu Y<br />
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PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2586-2589<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
RAPID COMMUNICATION<br />
Long-term results <strong>of</strong> endosurgical and open surgical approach<br />
for Zenker diverticulum<br />
Luigi Bonavina, Davide Bona, Medhanie Abraham, Greta Saino, Emmanuele Abate<br />
Luigi Bonavina, Davide Bona, Medhanie Abraham, Greta<br />
Saino, Emmanuele Abate, University <strong>of</strong> Milano, Department<br />
<strong>of</strong> Medical and Surgical Sciences, Section <strong>of</strong> General Surgery,<br />
I.R.C.C.S Policlinico San Donato, Italy<br />
Correspondence to: Pr<strong>of</strong>essor Luigi Bonavina, U.O. Chirurgia<br />
Generale, I.R.C.C.S. Policlinico San Donato Via Morandi 30,<br />
20137 San Donato Milanese (Milano),<br />
Italy. luigi.bonavina@unimi.it<br />
Telephone: +39-2-52774621 Fax: +39-2-52774622<br />
Received: 2007-01-15 Accepted: 2007-01-31<br />
Abstract<br />
AIM: To assess the effectiveness <strong>of</strong> minimally invasive<br />
versus traditional open surgical approach in the treatment<br />
<strong>of</strong> Zenker diverticulum.<br />
METHODS: Between 1976 and 2006, 297 patients<br />
underwent transoral stapling (n = <strong>18</strong>1) or stapled<br />
diverticulectomy and cricopharyngeal myotomy<br />
(n = 116). Subjective and objective evaluations <strong>of</strong> the<br />
outcome <strong>of</strong> the two procedures were made at 1 and<br />
6 mo after operation, and then every year. Long-term<br />
follow-up data were available for a subgroup <strong>of</strong> patients<br />
at a minimum <strong>of</strong> 5 and 10 years.<br />
RESULTS: The operative time and hospital stay<br />
were markedly reduced in patients undergoing the<br />
endosurgical approach. Overall, 92% <strong>of</strong> patients<br />
undergoing the endosurgical approach and 94% <strong>of</strong> those<br />
undergoing the open approach were symptom-free or<br />
were significantly improved after a median follow-up <strong>of</strong><br />
27 and 48 mo, respectively. At a minimum follow-up <strong>of</strong><br />
5 and 10 years, most patients were asymptomatic after<br />
both procedures, except for those individuals undergoing<br />
an endosurgical procedure for a small diverticulum (< 3<br />
cm).<br />
CONCLUSION: Both operations relieve the outflow<br />
obstruction at the pharyngoesophageal junction,<br />
indicating that cricopharyngeal myotomy has an<br />
important therapeutic role in this disease independent <strong>of</strong><br />
the resection <strong>of</strong> the pouch and <strong>of</strong> the surgical approach.<br />
Diverticula smaller than 3 cm represent a formal<br />
contraindication to the endosurgical approach because<br />
the common wall is too short to accommodate one<br />
cartridge <strong>of</strong> staples and to allow complete division <strong>of</strong> the<br />
sphincter.<br />
© 2007 The WJG Press. All rights reserved.<br />
www.wjgnet.com<br />
Key words: Esophagus; Zenker diverticulum; Cricopharyngeal<br />
myotomy; Diverticulectomy; Dysphagia; Aspiration<br />
pneumonia<br />
Bonavina L, Bona D, Abraham M, Saino G, Abate E. Longterm<br />
results <strong>of</strong> endosurgical and open surgical approach for<br />
Zenker diverticulum. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>):<br />
2586-2589<br />
http://www.wjgnet.com/1007-9327/13/2586.asp<br />
INTRODUCTION<br />
Surgical resection has represented the therapy <strong>of</strong> choice<br />
for Zenker diverticulum for many decades. Only during<br />
the second half <strong>of</strong> the last century it was recognized that<br />
correction <strong>of</strong> the functional obstruction caused by the<br />
upper esophageal sphincter is an important component<br />
<strong>of</strong> the surgical procedure [1,2] . Recent developments<br />
in minimally invasive surgery have led to the use <strong>of</strong><br />
endoscopic stapling devices to divide the septum between<br />
the esophagus and the pouch in order to relieve the<br />
outflow obstruction at the pharyngoesophageal junction [3,4] ,<br />
but no very long-term follow-up data (> 10 years) have<br />
been reported yet with this procedure. The aim <strong>of</strong> this<br />
retrospective study was to compare the late outcome <strong>of</strong><br />
the endosurgical and open surgical approach for Zenker<br />
diverticulum.<br />
MATERIALS AND METHODS<br />
Subjects<br />
Three-hundred and seventy consecutive patients underwent<br />
surgery for symptomatic Zenker diverticulum between 1976<br />
and 2006 in our institution. During this 30-year study period,<br />
a variety <strong>of</strong> surgical procedures were performed, including<br />
transoral stapling (n = <strong>18</strong>1), diverticulectomy and myotomy<br />
(n = 167), diverticulopexy and myotomy (n = 12), myotomy<br />
alone (n = 5), diverticulectomy alone (n = 4), diverticulum<br />
invagination (n = 1). Since 1992, when endostaplers became<br />
available for laparoscopic surgery [3,4] , transoral endostapling<br />
has become the preferred approach to the treatment <strong>of</strong><br />
pharyngoesophageal diverticulum in our institution. The<br />
outcomes <strong>of</strong> the two most common and recently performed<br />
techniques, i.e., transoral endostapling (n = <strong>18</strong>1), and stapled<br />
open resection plus cricopharyngeal myotomy (n = 116),<br />
form the basis <strong>of</strong> this report.<br />
Preoperative workup included barium swallow, upper
Bonavina L et al . Surgery <strong>of</strong> Zenker diverticulum 2587<br />
gastrointestinal endoscopy, and esophageal manometry<br />
in the majority <strong>of</strong> patients. At endoscopy, the depth <strong>of</strong><br />
the diverticulum (cm) was measured from the upper<br />
esophageal sphincter to the bottom <strong>of</strong> the pouch. The<br />
remaining esophagus was examined for the presence <strong>of</strong><br />
associated disease. A thin guide-wire inserted at the end<br />
<strong>of</strong> the endoscopic examination was <strong>of</strong>ten used to assist<br />
in positioning the manometric catheter. More recently,<br />
pharyngoesophageal transit scintigraphy was performed<br />
pre- and postoperatively in individuals undergoing the<br />
endosurgical approach. The patients were kept on a<br />
clear liquid diet the day before the operation. Whenever<br />
necessary, especially in elderly individuals, intravenous<br />
antibiotics, intensive respiratory physiotherapy, and<br />
nutritional support were administered before surgery.<br />
Technique <strong>of</strong> transoral endostapling<br />
The operation was routinely performed under general<br />
endotracheal anesthesia. The surgeon was sitting behind<br />
the patient’s head. The hypopharynx was entered with a<br />
modified Weerda diverticuloscope (Storz) which was gently<br />
advanced right behind the endotracheal tube until the<br />
cervical esophagus was reached. A 5 mm wide-angle 0°<br />
telescope connected to a cold-light source and a videocamera<br />
allowed to insert the instrument under vision with<br />
a magnified vision <strong>of</strong> the operative field on a television<br />
screen. By slowly withdrawing the instrument, the septum<br />
between the esophagus and diverticulum was identified<br />
and centered in the operative field. The two self-retracting<br />
valves <strong>of</strong> the diverticuloscope, which can be approximated<br />
and angulated to fit the patient’s hypopharyngeal anatomy,<br />
were allowed to enter the diverticulum and esophageal<br />
lumen, respectively. The length <strong>of</strong> the diverticulum (cm)<br />
was measured using a graduated rod. This maneuver<br />
also allowed to straighten the pouch and to elongate the<br />
common wall. An ETS 35 linear endostapling device<br />
(Ethicon Endo-surgery) was used to divide the septum. The<br />
anvil was placed in the lumen <strong>of</strong> the diverticulum and the<br />
cartridge into the lumen <strong>of</strong> the cervical esophagus. The<br />
instrument jaws were approximated across the septum in<br />
the midline before firing. With a single application <strong>of</strong> the<br />
endostapler, the posterior esophageal wall was sutured to<br />
the wall <strong>of</strong> the diverticulum, and the tissue was transected<br />
between three rows <strong>of</strong> staples on each side. Multiple<br />
stapler applications might be necessary according to the<br />
size <strong>of</strong> the diverticulum. Electrocoagulating endosurgical<br />
scissors might be used to complete the section at the distal<br />
end <strong>of</strong> the staple line. After removal <strong>of</strong> the stapler, the<br />
two wound edges retracted laterally due to the division<br />
<strong>of</strong> the cricopharyngeal muscle. A gastrographin swallow<br />
study was performed on the first postoperative day. The<br />
patient was then allowed to drink and eat a s<strong>of</strong>t diet and<br />
discharged from the hospital.<br />
Technique <strong>of</strong> open diverticulectomy and cricopharyngeal<br />
myotomy<br />
The operation was performed under general anesthesia,<br />
local anesthesia, or C5-C6 superselective spinal anesthesia.<br />
The patient was positioned supine on the operating<br />
table with a small pillow under the shoulders. The head<br />
was hyperextended and slightly turned to the right side.<br />
The skin incision, centered at the level <strong>of</strong> the cricoid<br />
cartilage, was made along the anterior border <strong>of</strong> the left<br />
sternocleidomastoid muscle. The subcutaneous tissue<br />
and platysma were divided. The pharynx and cervical<br />
esophagus were exposed by retracting the sternocleidomastoid<br />
and carotid sheath laterally, and the larynx and<br />
thyroid gland medially. The omohyoid muscle, middle<br />
thyroid vein, and inferior thyroid artery were divided.<br />
Care was taken not to injury the recurrent laryngeal nerve<br />
which runs in the tracheoesophageal groove. The diverticulum<br />
was identified, grasped with Duval forceps, and<br />
retracted cephalad. The loose connective tissue surrounding<br />
the pouch was dissected to identify its neck on the<br />
posterior pharyngeal wall. The transverse fibers <strong>of</strong> the<br />
cricopharyngeal muscle could be seen just below the neck<br />
<strong>of</strong> the diverticulum. At this point, right-angle forceps<br />
could be used to develop a dissection plane inferiorly<br />
between the muscolaris and mucosa, and myotomy was<br />
performed using curved scissors for a length <strong>of</strong> about 5<br />
cm on the cervical esophagus. The edges <strong>of</strong> the muscle<br />
were gently separated until the underlying mucosa was<br />
exposed. A Foley catheter inserted through the mouth and<br />
progressively withdrawn with the balloon inflated might<br />
be useful to distend the pharyngoesophageal junction<br />
during division <strong>of</strong> the muscle layer. The diverticulum<br />
was then transected using a TA 30 linear stapler (Tyco). A<br />
gastrographin swallow study was routinely performed on<br />
postoperative d 2 before resuming a s<strong>of</strong>t diet.<br />
Follow-up<br />
Patients were scheduled for an <strong>of</strong>fice visit at 1 and 6 mo<br />
after operation. Generally, a barium swallow study was<br />
obtained at the 1 year <strong>of</strong>fice visit and whenever dysphagia,<br />
pharyngo-oral regurgitation, or aspiration symptoms<br />
occurred. Patients were regularly interviewed by letter or<br />
by phone every year throughout the follow-up, and also<br />
invited to volunteer for upper gastrointestinal endoscopy<br />
and esophageal function studies.<br />
Statistical analysis<br />
A 2-tailed Student t test for paired values was used when<br />
appropriate for data analysis. P < 0.05 was considered<br />
statistically significant. Values are xpressed as mean ± SD.<br />
RESULTS<br />
The main demographic and clinical data and the outcome<br />
<strong>of</strong> the patient population are reported in Table 1.<br />
One patient died <strong>of</strong> pulmonary embolism during the<br />
postoperative period, giving an overall mortality rate<br />
<strong>of</strong> 0.3%. With the endosurgical approach there were<br />
8 conversions (4.4%) to open surgery due to difficult<br />
exposure <strong>of</strong> the septum and in one <strong>of</strong> these individuals a<br />
mucosal tear occurred during insertion <strong>of</strong> the endostapler.<br />
One transient left recurrent palsy and 1 wound hematoma<br />
requiring surgical revision occurred in patients undergoing<br />
the open approach; there were also 2 leaks from the<br />
staple line treated conservatively and healed within two<br />
weeks. The hospital stay was markedly reduced in patients<br />
undergoing the endosurgical approach.<br />
Eight patients in the endosurgical group (4.4%) com-<br />
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2588 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Table 1 Demographic data, clinical features and outcome in the<br />
patient population<br />
Transoral stapling Stapled resection +<br />
(n = <strong>18</strong>1) myotomy (n = 116)<br />
Age (median/range) 64/37-95 62/30-84<br />
Male/female ratio 3.5:1 2.7:1<br />
Dysphagia (%) 100 100<br />
Aspiration (%) 23 19<br />
Hiatal hernia/GERD (%) 9 12<br />
Weight loss (%) 32 17<br />
Pouch size - cm (median,range) 4/2.5-8 4/1-9<br />
Regional anesthesia (n) 0 15<br />
Mean operative time (min) 19 70<br />
Postop. mortality (%) 0 0.8<br />
Leaks from staple line (%) 0 1.7<br />
Recurrent nerve palsy (%) 0 0.8<br />
Dental injuries (%) 1.1 /<br />
Conversions (%) 4.4 /<br />
Mean hospital stay (d) 3 8<br />
Reoperation (%) 4.4 1.7<br />
Lost to follow-up (% patients) 9.9 <strong>18</strong>.1<br />
Median follow-up (mo) 27 48<br />
Asymptomatic (% patients) 92 94<br />
plained <strong>of</strong> persistent postoperative symptoms requiring<br />
an endosurgical procedure in 5, laser treatment by flexible<br />
endoscopy in 2, and open surgery in 1. Two patients in the<br />
open approach group (1.7%) required reoperation due to<br />
a recurrent diverticulum. Follow-up data were available for<br />
257 patients (86.8%). Overall, 92% <strong>of</strong> patients undergoing<br />
the endosurgical approach and 94% <strong>of</strong> those undergoing<br />
the open approach were symptom-free or significantly<br />
improved after a median follow-up <strong>of</strong> 27 and 48 mo,<br />
respectively. Pre- and postoperative manometric data<br />
in the two groups <strong>of</strong> patients are reported in Table 2.<br />
Radionuclide studies were performed in a subgroup <strong>of</strong><br />
patients (n = 15) undergoing the endosurgical approach<br />
and showed a statistically significant reduction <strong>of</strong> upper<br />
esophageal residual activity at 1 min compared with<br />
preoperative values (P = 0.006).<br />
Long-term follow-up data were available for a subgroup<br />
<strong>of</strong> patients at a minimum <strong>of</strong> 5 and 10 years after<br />
the endosurgical and open procedure. Most patients<br />
were asymptomatic after both procedures, except for<br />
those undergoing an endosurgical procedure for a small<br />
diverticulum (< 3 cm) (Table 3).<br />
DISCUSSION<br />
It is currently believed that inadequate opening <strong>of</strong> the<br />
upper esophageal sphincter, resulting from fibrosis<br />
<strong>of</strong> the cricopharyngeal muscle, considerably increases<br />
hypopharyngeal intrabolus pressure and leads to formation<br />
<strong>of</strong> a pulsion (Zenker’s) diverticulum [5-7] . It is for this<br />
reason that surgical resection or suspension <strong>of</strong> the pouch<br />
performed without a concomitant myotomy may fail to<br />
relieve dysphagia and to prevent complications or recurrence<br />
<strong>of</strong> the diverticulum. Cricopharyngeal myotomy creates a<br />
weak area in the muscle over which pharyngeal pressure<br />
can be distributed during swallowing [8-13] . Transoral stapling<br />
<strong>of</strong> the septum interposed between the esophagus and<br />
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Table 2 Comparison <strong>of</strong> pre- and postoperative manometric data<br />
Endosurgical (n = 43) Open (n = 24)<br />
Pre/post Pre/post<br />
Pharyngeal pressure (mmHg) 47.9/42.4 36.4/34.3<br />
UES resting pressure (mmHg) 52.4/31.5 b<br />
38/20 b<br />
U.E.S. residual pressure (mmHg) 3.4/2 6.2/0.7 a<br />
UES length (cm) 2.5/2.3 3.1/2.4 a<br />
a P < 0.05, b P < 0.01.<br />
Table 3 Late clinical follow-up results expressed as proportion<br />
<strong>of</strong> asymptomatic patients<br />
Endosurgical Open<br />
> 3 cm < 3 cm<br />
5 yr, n/n (%) 44/47 (93.6) 4/8 (50) 30/31 (96.7)<br />
10 yr, n/n (%) 29/35 (82.8) 2/6 (33.3) 16/19 (84.2)<br />
diverticulum leads to a similar physiological effect and the<br />
only difference is that this latter procedure does not remove<br />
the pouch itself but creates a common cavity [3] .<br />
Treatment <strong>of</strong> Zenker diverticulum is indicated, regardless<br />
<strong>of</strong> its size, to relieve the disabling symptoms <strong>of</strong> oropharyngeal<br />
dysphagia and pharyngo-oral regurgitation, and<br />
to prevent the life-threatening complication <strong>of</strong> aspiration<br />
pneumonia and lung abscess which commonly occur in the<br />
elderly population. The poor nutritional intake associated<br />
to the swallowing disorder and the tendency <strong>of</strong> the pouch<br />
to progressively enlarge represent the additional arguments<br />
in favor <strong>of</strong> early treatment. Pill-entrapment in the pouch<br />
is a further concern in patients with serious comorbidities<br />
who receive life-saving drug therapy [14] . Development <strong>of</strong> a<br />
squamous-cell carcinoma is a possible, although rare, longterm<br />
complication [15] .<br />
The results <strong>of</strong> this study show that both the transoral<br />
and surgical procedures are safe and effective in the treatment<br />
<strong>of</strong> Zenker diverticulum. Although it may be unfair<br />
to compare the more recent series <strong>of</strong> transorally treated<br />
patients with the historical cohort <strong>of</strong> surgically treated<br />
patients, it appears that the endosurgical approach has<br />
some distinct advantages. Unlike the traditional surgical<br />
approach, which varies depending on the preference <strong>of</strong> the<br />
individual surgeon, the endoscopic approach is focused on<br />
the upper esophageal sphincter. In fact, stapling the septum<br />
interposed between the pouch and cervical esophagus<br />
allows the creation <strong>of</strong> a common cavity with simultaneous<br />
section <strong>of</strong> the upper esophageal sphincter. Compared to<br />
the conventional surgical opera-tion, the advantages <strong>of</strong><br />
endostapling include absence <strong>of</strong> skin incision, shorter<br />
operative time, minimal or absent postoperative pain,<br />
quicker resumption <strong>of</strong> oral feeding, and shorter hospital<br />
stay [16] . An additional advantage <strong>of</strong> this approach is expected<br />
in patients who have undergone surgery in the left side<br />
<strong>of</strong> the neck or present with recurrent diverticulum after<br />
a conventional operation [17] . In such circumstances, the<br />
open approach may pose a major technical challenge to the<br />
surgeon and is associated with a high risk <strong>of</strong> recurrent nerve<br />
injury or leakage from the suture line.
Bonavina L et al . Surgery <strong>of</strong> Zenker diverticulum 2589<br />
The endoscopic approach may prove difficult in<br />
patients with cervical osteoarthritis, and in those with<br />
a reduced opening capacity <strong>of</strong> the mouth. The best<br />
indication to this procedure is represented by mediumsized<br />
diverticula in which at least two staple cartridges<br />
can be applied and an adequate cricopharyngeal myotomy<br />
can be achieved. Diverticula smaller than 3 cm in<br />
depth represent a formal contraindication to the endosurgical<br />
approach because the common wall is too short<br />
to accommodate one cartridge <strong>of</strong> staples and to allow<br />
complete division <strong>of</strong> the sphincter. This would result<br />
in an incomplete myotomy causing persistent dysphagia<br />
as it occurred in our series. Although the postoperative<br />
outcome <strong>of</strong> these patients, who are <strong>of</strong>ten elderly and<br />
compromised, suggests a greater comfort and a quicker<br />
recovery compared to the conventional operation, it should<br />
be taken into account that the endosurgical approach<br />
requires a general anesthesia. Therefore, in patients with<br />
excessive operative risk, a conventional operation carried<br />
out under regional anesthesia still remains the procedure<br />
<strong>of</strong> choice.<br />
At present, there is no evidence from high quality randomised<br />
controlled studies to establish which procedure is<br />
superior. It is clear that both operations relieve the outflow<br />
obstruction at the pharyngoesophageal junction, indicating<br />
that cricopharyngeal myotomy has an important therapeutic<br />
role in this disease independent <strong>of</strong> the resection <strong>of</strong> the<br />
pouch and <strong>of</strong> the surgical approach. Future trials may<br />
indicate the role <strong>of</strong> a tailored approach in the management<br />
<strong>of</strong> Zenker diverticulum [<strong>18</strong>] . Based on the findings <strong>of</strong> this<br />
study, we conclude that the endosurgical approach is as safe<br />
and effective as the open surgical procedure, provided that<br />
at least the entire length <strong>of</strong> the stapler cartridge (3 cm) can<br />
be applied to the septum. A small diverticulum limits access<br />
to the stapler head and it may not be possible to perform an<br />
adequate myotomy.<br />
COMMENTS<br />
Background<br />
The aim <strong>of</strong> surgery in Zenker diverticulum is to relieve outflow obstruction at the<br />
pharyngo-esophageal junction. This requires the performance <strong>of</strong> a cricopharyngeal<br />
myotomy and/or the resection <strong>of</strong> the pouch.<br />
Research frontiers<br />
It has been shown that effective surgery can be performed either through a<br />
transoral approach or through a transcervical approach.<br />
Innovations and breakthroughs<br />
The advent <strong>of</strong> laparoscopic instruments has represented a major technological<br />
advance in surgery over the past 15 years. Using a 5 mm telescope connected<br />
to a video-camera it is possible to insert a diverticuloscope through the mouth<br />
and divide the septum between the esophagus and Zenker diverticulum with an<br />
endostapler.<br />
Applications<br />
The transoral approach is increasingly used in the treatment <strong>of</strong> Zenker<br />
diverticulum. Compared to the conventional surgical operation the advantages<br />
<strong>of</strong> endostapling include shorter operative time, less postoperative pain, quicker<br />
recovery, and shorter hospital stay. Best long-term results are expected in patients<br />
with a > 3 cm pouch.<br />
Peer review<br />
This is an interesting review <strong>of</strong> the authors’ experience.The authors report on a<br />
large series <strong>of</strong> patients with Zenker diverticulum (n = 297). In this retrospective<br />
study, the transoral endosurgical approach (n = <strong>18</strong>1) was compared with a<br />
historical group <strong>of</strong> patients undergoing open diverticulectomy (n = 116). A subgroup<br />
<strong>of</strong> patients were followed up for 5 and 10 years, respectively.<br />
REFERENCES<br />
1 Belsey R. Functional disease <strong>of</strong> the esophagus. J Thorac<br />
Cardiovasc Surg 1966; 52: 164-<strong>18</strong>8<br />
2 Ferguson MK. Evolution <strong>of</strong> therapy for pharyngoesophageal<br />
(Zenker's) diverticulum. Ann Thorac Surg 1991; 51: 848-852<br />
3 Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique<br />
<strong>of</strong> esophagodiverticulostomy for Zenker's diverticulum. Ann<br />
Thorac Surg 1993; 56: 573-576<br />
4 Narne S, Bonavina L, Guido E, Peracchia A: Treatment <strong>of</strong><br />
Zenker’s diverticulum by endoscopic stapling. Endosurgery<br />
1993; 1: 1<strong>18</strong>-120<br />
5 Cook IJ, Gabb M, Panagopoulos V, Jamieson GG, Dodds WJ,<br />
Dent J, Shearman DJ. Pharyngeal (Zenker's) diverticulum<br />
is a disorder <strong>of</strong> upper esophageal sphincter opening.<br />
<strong>Gastroenterology</strong> 1992; 103: 1229-1235<br />
6 Shaw DW, Cook IJ, Jamieson GG, Gabb M, Simula ME, Dent<br />
J. Influence <strong>of</strong> surgery on deglutitive upper oesophageal<br />
sphincter mechanics in Zenker's diverticulum. Gut 1996; 38:<br />
806-811<br />
7 Venturi M, Bonavina L, Colombo L, Antoniazzi L, Bruno<br />
A, Mussini E, Peracchia A. Biochemical markers <strong>of</strong> upper<br />
esophageal sphincter compliance in patients with Zenker's<br />
diverticulum. J Surg Res 1997; 70: 46-48<br />
8 Ellis FH Jr, Crozier RE. Cervical esophageal dysphagia:<br />
indications for and results <strong>of</strong> cricopharyngeal myotomy. Ann<br />
Surg 1981; 194: 279-289<br />
9 Duranceau A, Rheault MJ, Jamieson GG. Physiologic response<br />
to cricopharyngeal myotomy and diverticulum suspension.<br />
Surgery 1983; 94: 655-662<br />
10 Bonavina L, Khan NA, DeMeester TR. Pharyngoesophageal<br />
dysfunctions. The role <strong>of</strong> cricopharyngeal myotomy. Arch Surg<br />
1985; 120: 541-549<br />
11 Lerut T, van Raemdonck D, Guelinckx P, Dom R, Geboes K.<br />
Zenker's diverticulum: is a myotomy <strong>of</strong> the cricopharyngeus<br />
useful? How long should it be? Hepatogastroenterology 1992; 39:<br />
127-131<br />
12 Bonavina L, Bettineschi F, Fontebasso V, Ruol A, Nosadini<br />
A, Peracchia A. Cricopharyngeal myotomy and stapling:<br />
treatment <strong>of</strong> choice for Zenker’s diverticulum. In: Nabeya K,<br />
Hanaoka T, Nogami H, eds. Recent advances in diseases <strong>of</strong> the<br />
esophagus, Tokyo: Springer Verlag, 1993: 207-211<br />
13 Mason RJ, Bremner CG, DeMeester TR, Crookes PF, Peters JH,<br />
Hagen JA, DeMeester SR. Pharyngeal swallowing disorders:<br />
selection for and outcome after myotomy. Ann Surg 1998; 228:<br />
598-608<br />
14 Hannan SA, Alusi G. Images in clinical medicine. Zenker's<br />
diverticulum. N Engl J Med 2006; 354: e24<br />
15 Huang BS, Unni KK, Payne WS. Long-term survival following<br />
diverticulectomy for cancer in pharyngoesophageal (Zenker's)<br />
diverticulum. Ann Thorac Surg 1984; 38: 207-210<br />
16 Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi<br />
L, Marotta G. Minimally invasive surgery for Zenker<br />
diverticulum: analysis <strong>of</strong> results in 95 consecutive patients.<br />
Arch Surg 1998; 133: 695-700<br />
17 Narne S, Bonavina L, Antoniazzi L, Cutrone C, Peracchia A.<br />
Safety and effectiveness <strong>of</strong> transoral stapling for recurrent<br />
Zenker diverticulum. In: Pinotti HW, Cecconello I, Felix VN,<br />
deOliveira MA, editors. Recent advances in Diseases <strong>of</strong> the<br />
Esophagus. Bologna: Monduzzi, 2001: 701-704<br />
<strong>18</strong> Sen P, Lowe DA, Farnan T. Surgical interventions for<br />
pharyngeal pouch. Cochrane Database Syst Rev 2005: CD004459<br />
S- Editor Wang J L- Editor Wang XL E- Editor Liu Y<br />
www.wjgnet.com
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2590-2595<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
RAPID COMMUNICATION<br />
Long-term results <strong>of</strong> subtotal colectomy with cecorectal<br />
anastomosis for isolated colonic inertia<br />
Antonio Iannelli, Thierry Piche, Raffaella Dainese, Pascal Fabiani, Albert Tran, Jean Mouiel, Jean Gugenheim<br />
Antonio Iannelli, Pascal Fabiani, Jean Mouiel, Jean<br />
Gugenheim, Service de Chirurgie Digestive - Université de Nice-<br />
Sophia-Antipolis, Faculté de Médecine, Nice, F-06107, France<br />
& Centre Hospitalier Universitaire de Nice, Pôle Digestif, Nice,<br />
F-06107, France<br />
Thierry Piche, Raffaella Dainese, Albert Tran, Service de<br />
Gastroentérologie - Université de Nice-Sophia-Antipolis, Faculté<br />
de Médecine, Nice, F-06107, France & Centre Hospitalier<br />
Universitaire de Nice, Pôle Digestif, Nice, F-06107, France<br />
Thierry Piche, Inserm U526, Nice, F-06107, France<br />
Correspondence to: Dr. Thierry Piche, Service d’Hépatogastroentérologie<br />
- Hôpital de l’Archet 2, 151 Route Saint-<br />
Antoine de Ginestière BP 3079, 06202-Nice-Cedex 3,<br />
France. tpiche@fc.horus-medical.fr<br />
Telephone: +33-4-92036168 Fax: +33-4-92036575<br />
Received: 2007-01-29 Accepted: 2007-02-14<br />
Abstract<br />
AIM: To evaluate the results <strong>of</strong> sub total colectomy with<br />
cecorectal anastomosis (STC-CRA) for isolated colonic<br />
inertia (CI).<br />
METHODS: Fourteen patients (mean age 57.5 ± 16.5<br />
year) underwent surgery for isolated CI between January<br />
1986 and December 2002. The mean frequency <strong>of</strong> bowel<br />
motions with the aid <strong>of</strong> laxatives was 1.2 ± 0.6 per week.<br />
All subjects underwent colonoscopy, anorectal manometry,<br />
cinedefaecography and colonic transit time (CTT). CI was<br />
defined as diffuse markers delay on CTT without evidence<br />
<strong>of</strong> pelvic floor dysfunction. All patients underwent STC-<br />
CRA. Long-term follow-up was obtained prospectively by<br />
clinical visits between October 2005 and February 2006<br />
at a mean <strong>of</strong> 10.5 ± 3.6 years (range 5-16 years) during<br />
which we considered the number <strong>of</strong> stool emissions, the<br />
presence <strong>of</strong> abdominal pain or digitations, the use <strong>of</strong> pain<br />
killers, laxatives and/or fibers. Patients were also asked if<br />
they were satisfied with the surgery.<br />
RESULTS: There was no postoperative mortality.<br />
Postoperative complications occurred in 21.4% (3/14). At<br />
the end <strong>of</strong> follow-up, bowel frequency was significantly<br />
(P < 0.05) increased to a mean <strong>of</strong> 4.8 ± 7.5 per day (range<br />
1-30). One patient reported disabling diarrhea. Two<br />
patients used laxatives less than three times per month<br />
without complaining <strong>of</strong> what they called constipation.<br />
Overall, 78.5% <strong>of</strong> patients would have chosen surgery<br />
again if necessary.<br />
CONCLUSION: STC-CRA is feasible and safe in patients<br />
www.wjgnet.com<br />
with CI achieving 79% <strong>of</strong> success at a mean followup<br />
<strong>of</strong> 10.5 years. A prospective controlled evaluation<br />
is warranted to verify the advantages <strong>of</strong> this surgical<br />
approach in patients with CI.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Constipation; Colonic inertia; Surgery;<br />
Subtotal colectomy; Cecorectal anastomosis<br />
Iannelli A, Piche T, Dainese R, Fabiani P, Tran A, Mouiel J,<br />
Gugenheim J. Long-term results <strong>of</strong> subtotal colectomy with<br />
cecorectal anastomosis for isolated colonic inertia. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2590-2595<br />
http://www.wjgnet.com/1007-9327/13/2590.asp<br />
INTRODUCTION<br />
Constipation is a common problem, with an estimated<br />
prevalence <strong>of</strong> 2%-20% [1,2] . It is one <strong>of</strong> the more presenting<br />
complaints to both general practitioners and<br />
gastroenterologists, and carries a significant economic<br />
impact. In the vast majority <strong>of</strong> patients with constipation,<br />
restoration <strong>of</strong> bowel habits is achieved by dietary fiber<br />
supplements or the use <strong>of</strong> laxatives.<br />
Severe lifestyle-altering chronic constipation is indeed<br />
rare and the surgical treatment <strong>of</strong> slow transit constipation<br />
concerns approximately 10% <strong>of</strong> patients after the failure<br />
<strong>of</strong> an aggressive and prolonged trial <strong>of</strong> laxatives, fibers<br />
and prokinetics [3] . Before referral for surgical treatment,<br />
an eventual contribution <strong>of</strong> pelvic floor dysfunction to<br />
constipation must be carefully diagnosed [4,5] . Indeed, it was<br />
shown that patients with slow transit constipation without<br />
outlet delay are the best responders to surgical treatment [6] .<br />
The standard surgical procedure for severe constipation<br />
is subtotal colectomy with ileorectal anastomosis (STC-<br />
IA) [7-9] . However, STC-IA leads to small bowel obstruction,<br />
in 8% to 50% <strong>of</strong> cases with a relaparotomy rate ranging<br />
from 0% to 14% (for review see [3] ). Furthermore, in recent<br />
studies, STC-IA also resulted in intractable diarrhoea in<br />
6% to 17% <strong>of</strong> patients with a disabling modification <strong>of</strong><br />
stool consistency in approximately 30% <strong>of</strong> patients 8 years<br />
after surgery [6] . Recurrent constipation requiring laxatives<br />
has been reported to occur in 27% <strong>of</strong> cases [10] . Subtotal<br />
abdominal colectomy with cecorectal anastomosis (STC-<br />
CRA) is an alternative procedure that has, for instance,<br />
received little attention. However, STC-CRA <strong>of</strong>fers the
Iannelli A et al . Subtotal colectomy for colonic inertia 2591<br />
theoretical advantage <strong>of</strong> retaining the ileocecal valve to<br />
enhance absorption <strong>of</strong> water within the terminal ileum,<br />
thus diminishing diarrhea. Sarli and colleagues have shown<br />
favorable short-term results <strong>of</strong> this surgical technique in<br />
a carefully selected series <strong>of</strong> patients with colonic inertia<br />
(CI) [11] . In the present study we report the long-term<br />
results <strong>of</strong> STC-CRA in a cohort 14 patients with isolated<br />
CI.<br />
MATERIALS AND METHODS<br />
Selection <strong>of</strong> patients<br />
Between January 1986 and December 2002, 14 patients<br />
with isolated chronic idiopathic slow transit constipation<br />
were operated upon using STC-CRA. All complained <strong>of</strong><br />
severe, long lasting and disabling constipation that strongly<br />
impaired their quality <strong>of</strong> life. None <strong>of</strong> them was capable <strong>of</strong><br />
having a bowel movement without the chronic use and/or<br />
association <strong>of</strong> laxatives, prokinetics and fibers. Preoperative<br />
investigations included full history and clinical expertise<br />
with inspection and digital examination, colonoscopy,<br />
barium enema, anorectal manometry, cinedefaecography,<br />
and colonic transit time (CTT) study to exclude an organic<br />
cause and confirm the diagnosis <strong>of</strong> colonic inertia. Patients<br />
with the irritable bowel syndrome, rectal outlet obstruction,<br />
organic or secondary constipation, megacolon, megarectum,<br />
volvulus, prolapse, colonic pseudo-obstruction, tumors,<br />
and polyps were excluded. All patients had an anatomically<br />
normal colon on colonoscopy or barium enema. All patients<br />
were considered for a surgical treatment <strong>of</strong> constipation<br />
using STC-CRA procedure. Long-term follow-up was<br />
performed by regular visits. The study was performed<br />
according to the declaration <strong>of</strong> Helsinky and patients gave<br />
written informed consent.<br />
Assessment <strong>of</strong> constipation and diagnosis <strong>of</strong> colonic<br />
inertia<br />
Clinical data included age, gender, past medical (emphasis<br />
was placed on metabolic and psychiatric disorders)<br />
and surgical history and treatments. Pertinent data<br />
regarding constipation included age at onset, presence<br />
<strong>of</strong> a recognizable precipitating event, number <strong>of</strong> bowel<br />
movements, stool consistency, presence <strong>of</strong> soiling,<br />
bloating, nausea, vomiting, abdominal, rectal or anal pain,<br />
use <strong>of</strong> laxatives (including enemas and fibers), pain killers<br />
and anorectal digitations. We appreciated the patients’<br />
perspectives focusing on what they called constipation<br />
and general well being. The number <strong>of</strong> bowel movements<br />
and stool consistency were evaluated through the daily<br />
completion <strong>of</strong> a symptom diary during four weeks.<br />
Patients were also asked for urological, gynecologic (e.g.<br />
regularity <strong>of</strong> menstrual cycle, age <strong>of</strong> menopause, history<br />
<strong>of</strong> prolonged labor) and sexual difficulties.<br />
For CTT measure 20 radiopaque markers were ingested<br />
in a capsule before breakfast, and a plain abdominal X-ray<br />
was taken on the third and fifth day. Laxatives and enemas<br />
were discontinued during this period. Delayed CTT was<br />
defined as the presence <strong>of</strong> at least 16 markers scattered<br />
diffusely throughout the colon on the fifth day after<br />
ingestion.<br />
All the individuals were submitted to both cinede-<br />
faecography and anorectal manometry, with special<br />
emphasis to the paradoxical puborectalis contraction.<br />
The anorectal manometry apparatus consisted <strong>of</strong> a<br />
pneumo-hydrolic perfusion system, which perfused<br />
distilled water in the left lateral position. Recordings<br />
included pressure at rest and during voluntary contraction<br />
(amplitude and duration), rectoanal inhibitory (RAIR)<br />
and excitatory reflexes, and threshold <strong>of</strong> urge sensation,<br />
maximum tolerable volume. A provoked expulsion<br />
test was performed with 50 mL air-inflated balloon in<br />
conjunction with anorectal manometry to screen for major<br />
dysfunctions <strong>of</strong> evacuation. A diagnosis <strong>of</strong> anismus was<br />
based on the findings <strong>of</strong> both digital examination and<br />
anorectal manometry. In each patient, short segment<br />
Hirschprung’s disease was excluded with a positive RAIR.<br />
The cinedefecating proctogram visualized the anatomy<br />
<strong>of</strong> the rectum and canal anal both at rest and during<br />
straining, and completed the pelvic floor assessment<br />
including sigmoidocele, rectocele, intussusception, and<br />
paradoxical puborectalis contraction. Failure <strong>of</strong> the<br />
anorectal angle to open during defecation and the degree<br />
<strong>of</strong> pelvic floor descent during defecation were both<br />
used to demonstrate anismus or conversely a descending<br />
perineum syndrome.<br />
Colonic inertia was defined as follows: (1) two or<br />
fewer stools per week with one or more <strong>of</strong> the following<br />
complaints: disabling abdominal pain, bloating, nausea<br />
and/or vomiting, difficulty in evacuation; (2) delayed<br />
CTT and absence <strong>of</strong> paradoxical puborectalis contraction<br />
on anorectal manometry and cinedefecography; (3) no<br />
evidence <strong>of</strong> an absent or equivocal RAIR evoking adult’s<br />
Hirschsprung’s disease on anorectal manometry.<br />
Operative technique<br />
All patients underwent bowel preparation with 4 liters <strong>of</strong><br />
polyethyleneglycol (PEG ® , B/Braum, Medical S.A. B.P. 331<br />
F-92107 Boulogne Cedex, France) the day before surgery.<br />
They also received one or more enemas on the evening<br />
before surgery. Single-dose ceftriaxone sodium (1 g) and<br />
metronidazole (1 g), diluted in 125 mg saline solution infused<br />
for 15 min, were administered to all patients intravenously<br />
at anaesthetic induction. Laparotomy was made through a<br />
midline incision, and the wound was protected by a plastic<br />
ring drape. The whole colon was mobilized from right to<br />
left; and the vascular pedicles to the colon were divided<br />
close to the bowel after having carefully identified the<br />
ileocolic vessels, which were preserved. The rectum was<br />
transected below the level <strong>of</strong> the sacral promontory and the<br />
head <strong>of</strong> the circular stapler was introduced into the rectal<br />
stump. Appendectomy was also performed. The caecum<br />
was mobilized enough to be brought into the pelvis with<br />
no rotation. The stapler was introduced into the ascending<br />
colon, and an antiperistaltic caecorectostomy was made<br />
between the base <strong>of</strong> the caecum and the rectal stump. The<br />
ascending colon was transected a few centimeters above the<br />
ileocecal junction with a linear stapler. No drain was left at<br />
the end <strong>of</strong> the procedure.<br />
Follow-up assessment<br />
Long-term follow-up was obtained prospectively by<br />
clinical visits planned between October 2005 and February<br />
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2592 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
2006 with independent researchers who were not involved<br />
in the preoperative management <strong>of</strong> patients. Before the<br />
visit, subjects had to complete the 4-weeks daily diary<br />
to evaluate the number <strong>of</strong> stool emissions per day and<br />
stool consistency. During the visit, all preoperative data<br />
(e.g. symptoms and treatments) pertaining to digestive,<br />
urological or gynecological tract were analyzed alongside<br />
with overall health and degree <strong>of</strong> satisfaction after<br />
surgery. In particular, we considered the number <strong>of</strong> stool<br />
emissions, the presence <strong>of</strong> abdominal pain or digitations,<br />
the use <strong>of</strong> pain killers, laxatives and/or fibers. Patients<br />
were also asked if they would have chosen surgery again<br />
if necessary. The long-term outcomes were to evaluate the<br />
number <strong>of</strong> stool emissions as well as stool consistency, the<br />
need for digitations, the use <strong>of</strong> laxatives, painkillers, the<br />
requirement <strong>of</strong> fibers in diet, the presence <strong>of</strong> abdominal<br />
pain and the overall satisfaction with surgery.<br />
Statistical analysis<br />
Data are given as percentage and mean ± SD. Comparisons<br />
<strong>of</strong> quantitative variables were performed using<br />
non-parametric Mann-Withney U test. The χ 2 square was<br />
used to compare qualitative variables. A P < 0.05 was<br />
considered significant.<br />
RESULTS<br />
Preoperative characteristics <strong>of</strong> patients<br />
All patients were females with a mean age <strong>of</strong> 57.5 (range<br />
24-72) years. Eight patients (57.1%) had psychiatric<br />
disorders such as anxiety or depression, necessitating<br />
psychotropic drugs. No formal contraindication for<br />
surgery was found at psychiatric evaluation. One patient<br />
underwent psychotherapy for one year before being<br />
considered for surgery. Two patients had a non-insulindependent<br />
diabetes mellitus and one had hypothyroidism.<br />
Urinary symptoms were present in ten patients (71.4%),<br />
with urinary incontinence being the most frequent<br />
complaint.<br />
Eight patients (57.1%) reported a lifelong history <strong>of</strong><br />
constipation, and in the remaining the mean duration <strong>of</strong><br />
symptoms was more than 10 yr. A precipitating factor was<br />
identified in seven patients (50%). The mean frequency<br />
<strong>of</strong> bowel movements with the aid <strong>of</strong> laxatives, enemas<br />
or digitations was 1.2 ± 0.6 per week (range 4-30 d). All<br />
patients’ complained <strong>of</strong> abdominal pain and bloating.<br />
Digitations were used by 71.4% <strong>of</strong> patients. Eight<br />
patients had a total <strong>of</strong> 12 abdominal operations. The<br />
most common operation was hysterectomy (50%); four<br />
patients had a left colectomy for “chronic constipation”;<br />
and two patients had a previous small bowel obstruction<br />
necessitating surgery. Three patients had rectocele repair,<br />
and one had haemorrhoidectomy (Milligan and Morgan’s<br />
procedure). Four patients (28.5%) needed pain killers. Five<br />
patients (35.7%) regularly used a high fibers rich dietary<br />
regimen. All patients reported their symptoms as having a<br />
major interference with their work or life activities.<br />
Transit study revealed diffuse marker delay in all patients.<br />
Anorectal manometry confirmed the presence <strong>of</strong> a RAIR<br />
in all patients. Neither anorectal manometry nor CD revealed<br />
Hirshprung disease. One patient had a small anterior<br />
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rectocele (4 cm) that emptied completely during evacuation.<br />
A diagnosis <strong>of</strong> isolated CI was done confirmed in all<br />
patients.<br />
Postoperative complications<br />
Ten patients (71.4%) were operated with the open<br />
technique, and the remaining 29.9% were operated with<br />
the laparoscopic technique. There was no peroperative or<br />
postoperative mortality. Postoperative complication rate<br />
was 21.4%. One patient had a hemothorax following venous<br />
central line insertion, requiring drainage; one patient had<br />
an intrabdominal collection that was successfully treated<br />
with CT-guided percutaneous drainage; one more patient<br />
underwent relaparotomy for bleeding with hypothensive<br />
shock on postoperative day two. All complications were<br />
recorded in patients operated by laparotomy.<br />
Follow-up<br />
Bowel habit: All patients were alive in 2006 and invited<br />
to the clinic after they completed the 4-weeks daily<br />
symptom diary evaluating stool frequency and consistency.<br />
Patients were assessed at a mean <strong>of</strong> 10.5 (range 5-16) yr<br />
after surgery. Table 1 summarizes individual clinical data<br />
regarding long-term clinical outcomes. As compared<br />
with preoperative bowel habit, the bowel frequency was<br />
significantly (P < 0.05) increased to a mean <strong>of</strong> 4.8 ± 7.5<br />
per d (range 1-30). The stool consistency was s<strong>of</strong>t in 11<br />
patient (78.5%) and liquid in three (21.4%). Overall 11<br />
patients (78.5%) reported perfect continence, two patients<br />
(14.2%) had less than one episode <strong>of</strong> soiling (incontinence)<br />
per week. One patient with preexisting psychiatric disorder<br />
developed disabling diarrhoea (30 bowel movements),<br />
accompanied with bloating and incontinence, and refused<br />
any further treatment.<br />
Seven patients (50%) had less than one episode per<br />
week <strong>of</strong> mild abdominal pain with bloating. Two patients<br />
(14.2%) used laxatives less than three times per month.<br />
One patient (7.1%) with a stenosis <strong>of</strong> the anal canal after<br />
surgery for hemorrhoids used enemas twice per week.<br />
None required digitation. Three patients (21.4%) reported<br />
new symptoms including difficult evacuation in two and<br />
rectal pain in one. Anti-diarrhea agents were utilized by<br />
three patients (21.4%) less than three times per month.<br />
None required the addition <strong>of</strong> fibers or other dietary<br />
changes.<br />
Self-reported satisfaction: Eleven patients (78.5%) would<br />
have chosen surgery again if necessary, whereas 3 patients<br />
(21.4%) were not satisfied with the results <strong>of</strong> surgery,<br />
considering their situation as unchanged (2 patients) or<br />
worse (1 patient).<br />
DISCUSSION<br />
In this study, we have shown that STC-CRA resulted in a<br />
78.5% rate <strong>of</strong> success in 14 patients with colonic inertia<br />
after a long-term follow-up. Postoperative complications<br />
occurred in 21.4% <strong>of</strong> patients operated by laparotomy and<br />
there was no mortality. Secondary morbidity was acceptable,<br />
mainly mild abdominal pain, without any significant<br />
recurrence <strong>of</strong> constipation and no re-intervention for this<br />
condition.
Iannelli A et al . Subtotal colectomy for colonic inertia 2593<br />
Table 1 Individual data <strong>of</strong> long-term clinical outcomes for 14 patients operated by subtotal colectomy with cecorectal anastomosis for<br />
colonic inertia<br />
Pts Follow-up (yr) Bowel movements Abdominal pain Laxatives Digitations Pain killers Fibers<br />
P < 0.05 P = 0.002 P = 0.001 P = 0.0001 P = 0.03 P = 0.01<br />
Before After Before After Before After Before After Before After Before After<br />
(per week) (per day)<br />
1 5 0.2 9.2 Yes No Yes No Yes No No No Yes No<br />
2 8 1.2 2.2 Yes No Yes No Yes No No No Yes No<br />
3 12 1.5 2 Yes No Yes No Yes No No No No No<br />
4 9 0.2 1.2 Yes No Yes No Yes No No No No No<br />
5 13 2 2 Yes Yes Yes No No No No No No No<br />
6 5 0.5 1.6 Yes Yes Yes No Yes No No No No No<br />
7 15 1.2 2 Yes No Yes No No No No No No No<br />
8 14 1.2 2.5 Yes No Yes No Yes No Yes No Yes No<br />
9 8 1.2 30 Yes Yes Yes Yes Yes No Yes No No No<br />
10 6 0.5 2.5 Yes No Yes No Yes No Yes No No No<br />
11 13 2 1.7 Yes Yes Yes Yes No No Yes No No No<br />
12 16 1.7 6 Yes No Yes No Yes No No No Yes No<br />
13 12 1.7 2 Yes Yes Yes No Yes No No No No No<br />
14 11 1.7 2.3 Yes Yes Yes No No No No No No No<br />
Pts: patients. Bowel movements are mean numbers obtained from a 30-d diary. P values given in the second line are statistical comparisons between outcome<br />
measured before and after surgery. Quantitative and qualitative variables are compared using Mann-Withney U test and χ 2 square respectively.<br />
STC-IA has been proposed as a treatment <strong>of</strong> choice <strong>of</strong><br />
CI when well documented and assuming the failure <strong>of</strong> a<br />
prolonged trial <strong>of</strong> laxatives, prokinetics or fibers. However,<br />
a recent review [12] has pointed out that this procedure<br />
may be less than satisfactory in consideration <strong>of</strong> the large<br />
variations <strong>of</strong> success rates ranging from 39% to 100%,<br />
the considerable morbidity (mainly occlusion), and the<br />
recurrence <strong>of</strong> constipation leading to a re-intervention rate<br />
<strong>of</strong> 14%. Thaler and colleagues underscored that quality <strong>of</strong><br />
life is significantly reduced after STC-IA mostly because<br />
<strong>of</strong> abdominal pain [13] .<br />
With the introduction <strong>of</strong> methods that enable the<br />
evaluation <strong>of</strong> pelvic floor dysfunction, it has become <strong>of</strong><br />
crucial importance to divide patients with severe constipation<br />
into those with CI and those with a predominant altered<br />
pelvic floor function. Indeed, there is growing acceptance<br />
that the presence <strong>of</strong> outlet obstruction [14] , alterations<br />
in rectal sensitivity [15] or megarectum [16] associated with<br />
slow transit constipation are predictive <strong>of</strong> a low rate <strong>of</strong><br />
success <strong>of</strong> surgical treatment. Knowles et al have observed<br />
higher functional results <strong>of</strong> STC-IA when CTT, anorectal<br />
manometry and cinedefaecography were systematically<br />
performed [12] . In the present prospective study, a thorough<br />
preoperative physiologic evaluation permitted the selection<br />
<strong>of</strong> patients with CI and without outlet delay as candidates<br />
to STC-CRA. However, as in other studies, our series<br />
was associated with persistent abdominal pain in 50% <strong>of</strong><br />
patients, even if <strong>of</strong> mild intensity. Although the causes <strong>of</strong><br />
persistent pain still remain unresolved, it can be cautiously<br />
speculated that the undiagnosed existence <strong>of</strong> abnormal<br />
upper GI motility may play a role [17,<strong>18</strong>] . Further studies are<br />
required to ascertain this hypothesis.<br />
Little is known about the efficacy <strong>of</strong> STC-CRA in<br />
patients with CI. It was suggested that STC-CRA might<br />
lead to poor results due to dilatation <strong>of</strong> the cecum and<br />
recurrence <strong>of</strong> constipation [19] . However, Sarli et al have<br />
recently shown favorable short-term results <strong>of</strong> STC-CRA<br />
in a carefully selected series <strong>of</strong> patients with CI [11] . The<br />
theoretical rationale for STC-CRA is that the sparing <strong>of</strong><br />
the ileo-caecal valve and the constitution <strong>of</strong> a physiologic<br />
reservoir, allowing the presence <strong>of</strong> colonic flora and<br />
the production <strong>of</strong> short chain fatty acids, may favour a<br />
normal stool consistency, normal absorption <strong>of</strong> water and<br />
electrolytes and also the prevention <strong>of</strong> renal and gallbladder<br />
lithiasis. In the present study, we have shown that the success<br />
rate <strong>of</strong> STC-CRA in CI achieved 79% at a mean follow-up<br />
<strong>of</strong> 10.5 yr after surgery. When compared to previous studies<br />
that investigated STC-IA for CI [6-8,15,17,<strong>18</strong>,20-28] , the slightly<br />
lower rate <strong>of</strong> success (79% vs 88% to 100%) recorded in the<br />
present study must be tempered by the longer follow-up (10.5<br />
yr vs 1 to 8.9 yr), the absence <strong>of</strong> postoperative complications<br />
related to the laparoscopic technique, the low postoperative<br />
morbidity, and the absence <strong>of</strong> recurrent disabling constipation.<br />
Indeed, the mean number <strong>of</strong> bowel motions was<br />
significantly increased in all patients after surgery, being<br />
disabling in only one, and none complained during the<br />
follow-up <strong>of</strong> what they called constipation. Although our<br />
data suggest that STC-CRA is associated with relief <strong>of</strong><br />
constipation in a majority <strong>of</strong> carefully selected patients with<br />
CI, the extent <strong>of</strong> abdominal pain/distension or emptying<br />
difficulties has been reported with large variations among<br />
studies from 17%-55% and 21%-51% respectively [29,30] ,<br />
suggesting that prospective controlled trial are required<br />
to precise morbidity and to compare between operative<br />
techniques. Taken together, we believe that STC-CRA is<br />
an effective technique to treat constipation in patients with<br />
isolated CI with a success rate that appears similar to that <strong>of</strong><br />
the STC-IA procedure.<br />
In the present study, a careful selection <strong>of</strong> patients<br />
was performed regarding the diagnosis <strong>of</strong> both constipation<br />
and CI. Acknowledging that the definition <strong>of</strong><br />
constipation is answerable only imperfectly, we have<br />
taken into account the opinion <strong>of</strong> our patients in the<br />
definition <strong>of</strong> constipation in both the selection and followup.<br />
Therefore, we do not think that the absence <strong>of</strong> an<br />
objective evaluation <strong>of</strong> the quality <strong>of</strong> life weakens the<br />
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2594 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
verbally expression <strong>of</strong> the well being <strong>of</strong> our patients at the<br />
end <strong>of</strong> the study.<br />
There is mounting evidence that psychological factors<br />
play a role in constipation. Nevertheless, it was shown<br />
that a history <strong>of</strong> psychiatric disease should not exclude<br />
patients from surgery, because the vast majority <strong>of</strong> patients<br />
with a psychiatric history still felt they were significantly<br />
improved following the surgical procedure [31] . In the<br />
present study, we had a special emphasis in the psychiatric<br />
evaluation <strong>of</strong> our patients, 8 <strong>of</strong> them showing depression,<br />
anxiety or hypochondriasis. Nevertheless, the success<br />
rate <strong>of</strong> surgery was high probably because the moderate<br />
severity <strong>of</strong> psychiatric illness in this selected series. Since<br />
the role <strong>of</strong> psychological factors on constipation is still<br />
unclear, a careful psychiatric evaluation should be included<br />
in the design <strong>of</strong> future studies aimed at evaluating surgical<br />
procedures for severe constipation.<br />
The use <strong>of</strong> laparoscopy to perform subtotal colectomy<br />
with ileorectal anastomosis has been reported as feasible<br />
and safe [32] . Thus laparoscopic techniques have been<br />
subsequently applied to the clinical problem <strong>of</strong> CI [33-35]<br />
and we have recently showed that STC-CRA may be<br />
performed laparoscopically with minimal postoperative<br />
morbidity [36] . In the current study, although we did not<br />
see any difference in long-term outcome <strong>of</strong> laparoscopic<br />
STC-CRA compared to the open technique, all 4 patients<br />
who underwent STC-CRA under laparoscopy were free <strong>of</strong><br />
postoperative complications suggesting that laparoscopy<br />
STC-CRA may be a procedure <strong>of</strong> choice when technically<br />
feasible.<br />
In conclusion, this study shows that STC-CRA is a<br />
feasible and safe procedure for patients with isolated CI<br />
achieving 79% <strong>of</strong> success after a long-term follow-up <strong>of</strong><br />
10.5 years <strong>of</strong> mean. The morbidity <strong>of</strong> this technique was<br />
related mainly to mild abdominal pain without recurrence<br />
<strong>of</strong> significant constipation. Further controlled studies are<br />
required to precise both morbidity and efficacy <strong>of</strong> STC-<br />
CRA in patients with CI.<br />
REFERENCES<br />
1 Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd.<br />
Functional constipation and outlet delay: a population-based<br />
study. <strong>Gastroenterology</strong> 1993; 105: 781-790<br />
2 Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ,<br />
Thompson WG, Whitehead WE, Janssens J, Funch-Jensen<br />
P, Corazziari E. U.S. householder survey <strong>of</strong> functional<br />
gastrointestinal disorders. Prevalence, sociodemography, and<br />
health impact. Dig Dis Sci 1993; 38: 1569-1580<br />
3 Knowles CH, Scott SM, Wellmer A, Misra VP, Pilot MA,<br />
Williams NS, Anand P. Sensory and autonomic neuropathy<br />
in patients with idiopathic slow-transit constipation. Br J Surg<br />
1999; 86: 54-60<br />
4 Wald A, Jafri F, Rehder J, Holeva K. Scintigraphic studies <strong>of</strong><br />
rectal emptying in patients with constipation and defecatory<br />
difficulty. Dig Dis Sci 1993; 38: 353-358<br />
5 Wexner SD, Jorge JM. Colorectal physiological tests: use or<br />
abuse <strong>of</strong> technology? Eur J Surg 1994; 160: 167-174<br />
6 Pikarsky AJ, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD.<br />
Long-term follow-up <strong>of</strong> patients undergoing colectomy for<br />
colonic inertia. Dis Colon Rectum 2001; 44: 179-<strong>18</strong>3<br />
7 Wexner SD, Daniel N, Jagelman DG. Colectomy for constipation:<br />
physiologic investigation is the key to success. Dis Colon Rectum<br />
1991; 34: 851-856<br />
8 Pemberton JH, Rath DM, Ilstrup DM. Evaluation and surgical<br />
www.wjgnet.com<br />
treatment <strong>of</strong> severe chronic constipation. Ann Surg 1991; 214:<br />
403-411; discussion 411-413<br />
9 Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term<br />
results <strong>of</strong> surgery for chronic constipation. Dis Colon Rectum<br />
1997; 40: 273-279<br />
10 Sample C, Gupta R, Bamehriz F, Anvari M. Laparoscopic<br />
subtotal colectomy for colonic inertia. J Gastrointest Surg 2005; 9:<br />
803-808<br />
11 Sarli L, Costi R, Sarli D, Roncoroni L. Pilot study <strong>of</strong> subtotal<br />
colectomy with antiperistaltic cecoproctostomy for the<br />
treatment <strong>of</strong> chronic slow-transit constipation. Dis Colon<br />
Rectum 2001; 44: 1514-1520<br />
12 Knowles CH, Scott M, Lunniss PJ. Outcome <strong>of</strong> colectomy for<br />
slow transit constipation. Ann Surg 1999; 230: 627-638<br />
13 Thaler K, Dinnewitzer A, Oberwalder M, Weiss EG, Nogueras<br />
JJ, Efron J, Vernava AM 3rd, Wexner SD. Quality <strong>of</strong> life after<br />
colectomy for colonic inertia. Tech Coloproctol 2005; 9: 133-137<br />
14 Kuijpers HC. Application <strong>of</strong> the colorectal laboratory in<br />
diagnosis and treatment <strong>of</strong> functional constipation. Dis Colon<br />
Rectum 1990; 33: 35-39<br />
15 Lundin E, Karlbom U, Pahlman L, Graf W. Outcome <strong>of</strong><br />
segmental colonic resection for slow-transit constipation. Br J<br />
Surg 2002; 89: 1270-1274<br />
16 Christiansen J, Rasmussen OO. Colectomy for severe slowtransit<br />
constipation in strictly selected patients. Scand J<br />
Gastroenterol 1996; 31: 770-773<br />
17 Verne GN, Hocking MP, Davis RH, Howard RJ, Sabetai MM,<br />
Mathias JR, Schuffler MD, Sninsky CA. Long-term response to<br />
subtotal colectomy in colonic inertia. J Gastrointest Surg 2002; 6:<br />
738-744<br />
<strong>18</strong> Redmond JM, Smith GW, Bar<strong>of</strong>sky I, Ratych RE, Goldsborough<br />
DC, Schuster MM. Physiological tests to predict longterm<br />
outcome <strong>of</strong> total abdominal colectomy for intractable<br />
constipation. Am J Gastroenterol 1995; 90: 748-753<br />
19 Sagar PM, Pemberton JH. Anorectal and pelvic floor function.<br />
Relevance <strong>of</strong> continence, incontinence, and constipation.<br />
Gastroenterol Clin North Am 1996; 25: 163-<strong>18</strong>2<br />
20 Mahendrarajah K, Van der Schaaf AA, Lovegrove FT,<br />
Mendelson R, Levitt MD. Surgery for severe constipation:<br />
the use <strong>of</strong> radioisotope transit scan and barium evacuation<br />
proctography in patient selection. Aust N Z J Surg 1994; 64:<br />
<strong>18</strong>3-<strong>18</strong>6<br />
21 Takahashi T, Fitzgerald SD, Pemberton JH. Evaluation and<br />
treatment <strong>of</strong> constipation. Rev Gastroenterol Mex 1994; 59:<br />
133-138<br />
22 Piccirillo MF, Reissman P, Wexner SD. Colectomy as treatment<br />
for constipation in selected patients. Br J Surg 1995; 82: 898-901<br />
23 Webster C, Dayton M. Results after colectomy for colonic<br />
inertia: a sixteen-year experience. Am J Surg 2001; <strong>18</strong>2: 639-644<br />
24 Nylund G, Oresland T, Fasth S, Nordgren S. Long-term<br />
outcome after colectomy in severe idiopathic constipation.<br />
Colorectal Dis 2001; 3: 253-258<br />
25 Aldulaymi BH, Rasmussen OO, Christiansen J. Long-term<br />
results <strong>of</strong> subtotal colectomy for severe slow-transit constipation<br />
in patients with normal rectal function. Colorectal Dis 2001; 3:<br />
392-395<br />
26 Mollen RM, Kuijpers HC, Claassen AT. Colectomy for slowtransit<br />
constipation: preoperative functional evaluation is<br />
important but not a guarantee for a successful outcome. Dis<br />
Colon Rectum 2001; 44: 577-580<br />
27 Glia A, Akerlund JE, Lindberg G. Outcome <strong>of</strong> colectomy for<br />
slow-transit constipation in relation to presence <strong>of</strong> smallbowel<br />
dysmotility. Dis Colon Rectum 2004; 47: 96-102<br />
28 FitzHarris GP, Garcia-Aguilar J, Parker SC, Bullard KM,<br />
Mad<strong>of</strong>f RD, Goldberg SM, Lowry A. Quality <strong>of</strong> life after<br />
subtotal colectomy for slow-transit constipation: both quality<br />
and quantity count. Dis Colon Rectum 2003; 46: 433-440<br />
29 Gasche C, Bakos S, Dejaco C, Tillinger W, Zakeri S, Reinisch<br />
W. IL-10 secretion and sensitivity in normal human intestine<br />
and inflammatory bowel disease. J Clin Immunol 2000; 20:<br />
362-370<br />
30 Platell C, Scache D, Mumme G, Stitz R. A long-term followup<br />
<strong>of</strong> patients undergoing colectomy for chronic idiopathic
Iannelli A et al . Subtotal colectomy for colonic inertia 2595<br />
constipation. Aust N Z J Surg 1996; 66: 525-529<br />
31 Dykes S, Smilgin-Humphreys S, Bass C. Chronic idiopathic<br />
constipation: a psychological enquiry. Eur J Gastroenterol<br />
Hepatol 2001; 13: 39-44<br />
32 Hasegawa H, Watanabe M, Baba H, Nishibori H, Kitajima M.<br />
Laparoscopic restorative proctocolectomy for patients with<br />
ulcerative colitis. J Laparoendosc Adv Surg Tech A 2002; 12:<br />
403-406<br />
33 Hong D, Lewis M, Tabet J, Anvari M. Prospective comparison<br />
<strong>of</strong> laparoscopic versus open resection for benign colorectal<br />
disease. Surg Laparosc Endosc Percutan Tech 2002; 12: 238-242<br />
34 Wexner SD, Reissman P, Pfeifer J, Bernstein M, Geron N.<br />
Laparoscopic colorectal surgery: analysis <strong>of</strong> 140 cases. Surg<br />
Endosc 1996; 10: 133-136<br />
35 Ho YH, Tan M, Eu KW, Leong A, Choen FS. Laparoscopicassisted<br />
compared with open total colectomy in treating slow<br />
transit constipation. Aust N Z J Surg 1997; 67: 562-565<br />
36 Iannelli A, Fabiani P, Mouiel J, Gugenheim J. Laparoscopic<br />
subtotal colectomy with cecorectal anastomosis for slowtransit<br />
constipation. Surg Endosc 2006; 20: 171-173<br />
S- Editor Zhu LH L- Editor Alpini GD E- Editor Liu Y<br />
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www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
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RAPID COMMUNICATION<br />
Effects <strong>of</strong> granulocyte-colony stimulating factor on peritoneal<br />
defense mechanisms and bacterial translocation after<br />
administration <strong>of</strong> systemic chemotherapy in rats<br />
Celal Cerci, Cagri Ergin, Erol Eroglu, Canan Agalar, Fatih Agalar, Sureyya Cerci, Mahmut Bulbul<br />
Celal Cerci, Erol Eroglu, Mahmut Bulbul, Suleyman Demirel<br />
University, School <strong>of</strong> Medicine, General Surgery Department,<br />
Isparta, Turkey<br />
Cagri Ergin, Pamukkale University, School <strong>of</strong> Medicine, Clinical<br />
Microbiology Department, Denizli, Turkey<br />
Canan Agalar, Kırıkkale University, School <strong>of</strong> Medicine,<br />
Infectious Diseases Department, Kırıkkale, Turkey<br />
Fatih Agalar, Kırıkkale University, School <strong>of</strong> Medicine, General<br />
Surgery Department, Kırıkkale, Turkey<br />
Sureyya Cerci, Suleyman Demirel University, School <strong>of</strong><br />
Medicine, Nuclear Medicine Department, Isparta, Turkey<br />
Correspondence to: Celal Cerci, Suleyman Demirel University,<br />
School <strong>of</strong> Medicine, General Surgery Department, Modernevler<br />
3103 sok. No.16, 32200, Isparta, Turkey. celalcerci@yahoo.com<br />
Telephone: +90-505-2933423 Fax: +90-246-2234736<br />
Received: 2007-01-<strong>18</strong> Accepted: 2007-03-01<br />
Abstract<br />
AIM: To investigate the effects <strong>of</strong> granulocyte-colony<br />
stimulating factor (G-CSF) on peritoneal defense<br />
mechanisms and bacterial translocation after systemic<br />
5-Fluorouracil (5-FU) administration.<br />
METHODS: Thirty Wistar albino rats were divided<br />
into three groups; the control, 5-FU and 5-FU + G-CSF<br />
groups. We measured bactericidal activity <strong>of</strong> the<br />
peritoneal fluid, phagocytic activity <strong>of</strong> polymorphonuclear<br />
leucocytes in the peritoneal fluid, total peritoneal<br />
cell counts and cell types <strong>of</strong> peritoneal washing fluid.<br />
Bacterial translocation was quantified by mesenteric<br />
lymph node, liver and spleen tissue cultures.<br />
RESULTS: Systemic 5-FU reduced total peritoneal cell<br />
counts, neutrophils and macrophage numbers. It also<br />
altered bactericidal activity <strong>of</strong> the peritoneal fluid and<br />
phagocytic activity <strong>of</strong> polymorphonuclear leucocytes in<br />
the peritoneal fluid. 5-FU also caused significant increase<br />
in frequencies <strong>of</strong> bacterial translocation at the liver and<br />
mesenteric lymph nodes. G-CSF decreased bacterial<br />
translocation, it significantly enhanced bactericidal<br />
activity <strong>of</strong> the peritoneal fluid and phagocytic activity <strong>of</strong><br />
polymorphonuclear leucocytes in the peritoneal fluid. It<br />
also increased total peritoneal cell counts, neutrophils<br />
and macrophage numbers.<br />
CONCLUSION: Systemic 5-FU administration caused<br />
bacterial translocation, decreased the bactericidal<br />
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activity <strong>of</strong> peritoneal fluid and phagocytic activity<br />
<strong>of</strong> polymorphonuclear leucocytes in the peritoneal<br />
fluid. G-CSF increased both bactericidal activity<br />
<strong>of</strong> the peritoneal fluid and phagocytic activity <strong>of</strong><br />
polymorphonuclear leucocytes in the peritoneal fluid, and<br />
prevented the bacterial translocation. We conclude that<br />
intraperitoneal GCSF administration protects the effects<br />
<strong>of</strong> systemic 5-FU on peritoneal defense mechanisms.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Granulocyte-colony stimulating factor;<br />
5-Fluorouracil; Bacterial translocation; Peritoneal defense<br />
mechanisms<br />
Cerci C, Ergin C, Eroglu E, Agalar C, Agalar F, Cerci S, Bulbul<br />
M. Effects <strong>of</strong> granulocyte-colony stimulating factor on<br />
peritoneal defense mechanisms and bacterial translocation<br />
after administration <strong>of</strong> systemic chemotherapy in rats. <strong>World</strong><br />
J Gastroenterol 2007; 13(<strong>18</strong>): 2596-2599<br />
http://www.wjgnet.com/1007-9327/13/2596.asp<br />
INTRODUCTION<br />
Chemotherapy is one <strong>of</strong> the most important methods<br />
in the therapy <strong>of</strong> malignant diseases. It has been widely<br />
used and it is well known that systemic chemotherapy has<br />
immunosuppressive effects [1] . 5-Fluorouracil (5-FU) has<br />
side effects, including leucopoenia, stomatitis, appetite<br />
loss, diarrhea, and mild fever like other chemotherapy<br />
agents [2,3] . It has been reported that a high dose <strong>of</strong> 5-FU<br />
<strong>of</strong>ten induces cytotoxicity in intestinal tissue that results in<br />
ulceration, diarrhea, and bacterial translocation [4-8] .<br />
Bacterial translocation is one <strong>of</strong> the most important<br />
causes <strong>of</strong> sepsis and multiple organ failure. Intestinal mucosa<br />
has a barrier function that prevents the colonization <strong>of</strong> the<br />
bacteria and the passage <strong>of</strong> bacteria and their toxins from<br />
the intestinal system into the systemic circulation. It has<br />
been shown that bacterial translocation is also augmented<br />
by shock, mesenteric ischemia, thermal injury, malnutrition,<br />
obstructive jaundice, and intestinal obstruction [9-14] .<br />
Granulocyte-colony stimulating factor (G-CSF)<br />
is a cytokine that is used to reverse the neutropenia<br />
associated with cytotoxic chemotherapy bone marrow and<br />
haemopoietic stem cell transplantation [15] . The role <strong>of</strong> GM-
2598 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Table 1 Effects <strong>of</strong> 5-FU and 5-FU + G-CSF administration on peritoneal defense mechanisms and systemic WBC counts. Figures are<br />
expressed as median (range)<br />
via the lymphatic system can easily pass into the systemic<br />
circulation and cause bacteriemia and septicemia [19] .<br />
Another possible pathway <strong>of</strong> septicemia is bacterial<br />
translocation defined as the passage <strong>of</strong> viable bacteria<br />
from the gastrointestinal tract through the epithelial<br />
mucosa into the lamina propria and then to the mesenteric<br />
lymph node and possibly other organs [20] , which may be<br />
important in immunosuppressive hosts.<br />
Although 5-FU is a widely used antineoplastic agent,<br />
the cytotoxicity <strong>of</strong> 5-FU is not limited to tumor tissue.<br />
Hematopoietic cells and normal epithelial cells <strong>of</strong> the<br />
gastrointestinal tract are susceptible to 5-FU induced<br />
cytotoxicity producing severe leukopenia and intestinal<br />
toxicity leading to lethal translocation <strong>of</strong> intestinal<br />
micr<strong>of</strong>lora [21-24] . In general our findings are in line with<br />
previous studies that have reported that systemic 5-FU<br />
administration causes epithelial barrier dysfunction <strong>of</strong> the<br />
rat intestine [25] , and causes bacterial translocation [26] .<br />
G-CSF is a pleitropic cytokine that has specific effects<br />
on the proliferation, differentiation, and activation <strong>of</strong><br />
neutrophils and enhances their phagocytic and bactericidal<br />
activity [27] . The attenuation <strong>of</strong> bacterial translocation<br />
by G-CSF administration may be related to several<br />
mechanisms. G-CSF has some qualitative and quantitative<br />
effects on peritoneal defense cells (e.g. macrophages,<br />
polymorphonuclear leukocytes) and this may facilitate the<br />
removing <strong>of</strong> the bacteria translocated in mesenteric lymph<br />
nodes. It was shown in a previous report that the decreased<br />
numbers <strong>of</strong> viable pneumococci were recovered from<br />
tracheobronchial lymph nodes from the G-CSF-treated<br />
splenectomized mice and the sham-operated mice vs saline<br />
solution-treated controls [28] . It is well known that bacterial<br />
products and/or secondary inflammatory mediators<br />
induced by an infection are the potent stimulators for the<br />
production <strong>of</strong> G-CSF [29] . The beneficial effects <strong>of</strong> G-CSF<br />
on chemotaxis, neutrophil, phagocytosis, and bactericidal<br />
activities have also been demonstrated in some studies [27,30] .<br />
In this study, we found that systemic 5-FU administration<br />
also led to significant changes in the total peritoneal<br />
Control (n : 10) 5-FU (n : 10) 5-FU + G-CSF (n : 10)<br />
Bactericidal activity <strong>of</strong> peritoneal fluid MIC90 (bacteria/mL) 17.90 (14.1-24.6) 9.40 (6.2-13.8) a<br />
19.20 (14.3-26.8)<br />
Phagocytic activity <strong>of</strong> PMNL 56.3 (48.3-62.6) 36 (25-51.6) a<br />
43.5 (37-58.6)<br />
Cell counts in peritoneal fluid 2000 (1500-2400) 950 (600-1200) a<br />
1380 (800-1900)<br />
Systemic WBC Counts 9000 (4000-14000) 2100 (1100-2600) a 3400 (2200-4600)<br />
a P < 0.05 vs control and 5-FU + G-CSF groups.<br />
Table 2 Cell types in peritoneal fluid. Values are presented as<br />
median (range)<br />
Groups n Neutrophil/mm 3 Macrophage/mm 3<br />
Control 10 88 (80-94) 14 (1-20)<br />
5-FU 10 68 (62-92) a<br />
8 (6-12) a<br />
5-FU + G-CSF 10 80 (73-87) 12 (6-15)<br />
a P < 0.05 vs control and 5-FU + G-CSF groups.<br />
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Table 3 Bacterial translocation <strong>of</strong> the groups<br />
Control 5-FU 5-FU + G-CSF<br />
Spleen 0 0 0<br />
Liver 0 2 0<br />
Mesenteric lymph node 1 5 0<br />
cell counts and cell types. The most affected cell type<br />
was macrophage. On the other hand, any significant<br />
differences in total cell counts and cell types could not<br />
be detected in the 5-FU + G-CSF group. We concluded<br />
that G-CSF increased the total peritoneal cell counts,<br />
neutrophil and macrophage counts when compared with<br />
the systemic 5-FU group. It has been reported that G-CSF<br />
administration increases the number <strong>of</strong> peritoneal exudates<br />
neutrophils, and the bactericidal activity <strong>of</strong> them, but does<br />
not affect the phagocytic activity <strong>of</strong> peritoneal exudates<br />
neutrophils [31] . However, G-CSF increases the number <strong>of</strong><br />
circulating neutrophils and enhances their functions [27,32,33] .<br />
In conclusion, the systemic 5-FU administration caused<br />
bacterial translocation, decreased the bactericidal activity <strong>of</strong><br />
peritoneal fluid, phagocytic activity <strong>of</strong> polymorphonuclear<br />
leucocytes in the peritoneal fluid and G-CSF increased<br />
both peritoneal and phagocytic activity <strong>of</strong> peritoneal fluid<br />
and prevented bacterial translocation. We conclude that<br />
intraperitoneal GCSF administration protects the effects<br />
<strong>of</strong> systemic 5-FU on peritoneal defense mechanisms.<br />
REFERENCES<br />
1 Cunliffe WJ, Sugarbaker PH. Gastrointestinal malignancy:<br />
rationale for adjuvant therapy using early postoperative<br />
intraperitoneal chemotherapy. Br J Surg 1989; 76: 1082-1090<br />
2 Dikken C, Sitzia J. Patients' experiences <strong>of</strong> chemotherapy:<br />
side-effects associated with 5-fluorouracil + folinic acid in the<br />
treatment <strong>of</strong> colorectal cancer. J Clin Nurs 1998; 7: 371-379<br />
3 Katona C, Kralovanszky J, Rosta A, Pandi E, Fonyad G, Toth K,<br />
Jeney A. Putative role <strong>of</strong> dihydropyrimidine dehydrogenase<br />
in the toxic side effect <strong>of</strong> 5-fluorouracil in colorectal cancer<br />
patients. Oncology 1998; 55: 468-474<br />
4 Kirmani S, Braly PS, McClay EF, Saltzstein SL, Plaxe SC, Kim<br />
S, Cates C, Howell SB. A comparison <strong>of</strong> intravenous versus<br />
intraperitoneal chemotherapy for the initial treatment <strong>of</strong><br />
ovarian cancer. Gynecol Oncol 1994; 54: 338-344<br />
5 Weiber S, Graf W, Glimelius B, Jiborn H, Pahlman L,<br />
Zederfeldt B. The effect <strong>of</strong> 5-fluorouracil on wound healing<br />
and collagen synthesis in left colon anastomoses. An<br />
experimental study in the rat. Eur Surg Res 1994; 26: 173-178<br />
6 Hananel N, Gordon PH. Effect <strong>of</strong> 5-fluorouracil and leucovorin<br />
on the integrity <strong>of</strong> colonic anastomoses in the rat. Dis Colon<br />
Rectum 1995; 38: 886-890<br />
7 Koruda MJ, Rolandelli RH. Experimental studies on the
Cerci C et al . Effects <strong>of</strong> GCSF on peritoneal defense mechanisms 2599<br />
healing <strong>of</strong> colonic anastomoses. J Surg Res 1990; 48: 504-515<br />
8 Unal AE, Cevikel MH, Ozgun H, Tunger A. Effect <strong>of</strong><br />
granulocyte-macrophage colony stimulating factor on bacterial<br />
translocation after experimental obstructive jaundice. Eur J<br />
Surg 2001; 167: 366-370<br />
9 Alexander JW, Boyce ST, Babcock GF, Gianotti L, Peck MD,<br />
Dunn DL, Pyles T, Childress CP, Ash SK. The process <strong>of</strong><br />
microbial translocation. Ann Surg 1990; 212: 496-510; discussion<br />
511-512<br />
10 Deitch EA. The role <strong>of</strong> intestinal barrier failure and bacterial<br />
translocation in the development <strong>of</strong> systemic infection and<br />
multiple organ failure. Arch Surg 1990; 125: 403-404<br />
11 Goris RJ, van Bebber IP, Mollen RM, Koopman JP. Does<br />
selective decontamination <strong>of</strong> the gastrointestinal tract prevent<br />
multiple organ failure? An experimental study. Arch Surg<br />
1991; 126: 561-565<br />
12 Deitch EA, Winterton J, Berg R. Effect <strong>of</strong> starvation, malnutrition,<br />
and trauma on the gastrointestinal tract flora and bacterial<br />
translocation. Arch Surg 1987; 122: 1019-1024<br />
13 MacFie J. Enteral versus parenteral nutrition: the significance<br />
<strong>of</strong> bacterial translocation and gut-barrier function. Nutrition<br />
2000; 16: 606-611<br />
14 Roscher R, Oettinger W, Beger HG. Bacterial micr<strong>of</strong>lora,<br />
endogenous endotoxin, and prostaglandins in small bowel<br />
obstruction. Am J Surg 1988; 155: 348-355<br />
15 Metcalf D. The colony stimulating factors. Discovery,<br />
development, and clinical applications. Cancer 1990; 65:<br />
2<strong>18</strong>5-2195<br />
16 Bergman N, Bercovici B, Sacks T. Antibacterial activity <strong>of</strong><br />
human amniotic fluid. Am J Obstet Gynecol 1972; 114: 520-523.<br />
17 Wilkinson PC. Neutrophil leucocyte function tests. In:<br />
Thompson RA. Techniques in clinical immunology. Oxford:<br />
Blackwell Scientific, 1977: 217-2<strong>18</strong><br />
<strong>18</strong> Giercksky KE. Secondary peritonitis-a major clinical problem.<br />
Scand J Gastroenterol Suppl 1984; 100: 3-5<br />
19 Hau T. Bacteria, toxins, and the peritoneum. <strong>World</strong> J Surg 1990;<br />
14: 167-175<br />
20 Berg RD, Garlington AW. Translocation <strong>of</strong> certain indigenous<br />
bacteria from the gastrointestinal tract to the mesenteric lymph<br />
nodes and other organs in a gnotobiotic mouse model. Infect<br />
Immun 1979; 23: 403-411<br />
21 Von Bultzingslowen I, Adlerberth I, Wold AE, Dahlen G,<br />
Jontell M. Oral and intestinal micr<strong>of</strong>lora in 5-fluorouracil<br />
treated rats, translocation to cervical and mesenteric lymph<br />
nodes and effects <strong>of</strong> probiotic bacteria. Oral Microbiol Immunol<br />
2003; <strong>18</strong>: 278-284<br />
22 Deng GY, Liu YW, He GZ, Jiang ZM. Effect <strong>of</strong> dietary fiber on<br />
intestinal barrier function <strong>of</strong> 5-Fu stressed rats. Res Exp Med<br />
(Berl) 1999; 199: 111-119<br />
23 Nomoto K, Yokokura T, Nomoto K. Prevention <strong>of</strong> 5-fluorouracilinduced<br />
infection with indigenous Escherichia coli in tumorbearing<br />
mice by nonspecific immunostimulation. Can J Microbiol<br />
1992; 38: 774-778<br />
24 Itoh N, Nishimura H, Matsuguchi T, Yajima T, Mokuno Y,<br />
Hiromatsu T, Nimura Y, Yoshikai Y. CD8 alpha-deficient mice<br />
are highly susceptible to 5-fluorouracil-induced lethality. Clin<br />
Diagn Lab Immunol 2002; 9: 550-557<br />
25 Hirata K, Horie T. Changes in intestinal absorption <strong>of</strong><br />
5-fluorouracil-treated rats. Pharmacol Toxicol 1999; 85: 33-36<br />
26 Tancrede CH, Andremont AO. Bacterial translocation and<br />
gram-negative bacteremia in patients with hematological<br />
malignancies. J Infect Dis 1985; 152: 99-103<br />
27 Roilides E, Walsh TJ, Pizzo PA, Rubin M. Granulocyte colonystimulating<br />
factor enhances the phagocytic and bactericidal<br />
activity <strong>of</strong> normal and defective human neutrophils. J Infect<br />
Dis 1991; 163: 579-583<br />
28 Hebert JC, O'Reilly M, Gamelli RL. Protective effect <strong>of</strong><br />
recombinant human granulocyte colony-stimulating factor<br />
against pneumococcal infections in splenectomized mice. Arch<br />
Surg 1990; 125: 1075-1078<br />
29 Nelson S. Role <strong>of</strong> granulocyte colony-stimulating factor<br />
in the immune response to acute bacterial infection in the<br />
nonneutropenic host: an overview. Clin Infect Dis 1994; <strong>18</strong><br />
Suppl 2: S197-S204<br />
30 Sartorelli KH, Silver GM, Gamelli RL. The effect <strong>of</strong> granulocyte<br />
colony-stimulating factor (G-CSF) upon burn-induced defective<br />
neutrophil chemotaxis. J Trauma 1991; 31: 523-529; discussion<br />
529-530<br />
31 Tuo H, Sugiyama M, Nakashima M, Abe N, Atomi Y. Effects<br />
<strong>of</strong> granulocyte colony-stimulating factor on neutrophils and<br />
inflammatory cytokines in the early stage <strong>of</strong> severe acute<br />
pancreatitis in rats. J Gastroenterol 2005; 40: <strong>18</strong>6-191<br />
32 Pajkrt D, Manten A, van der Poll T, Tiel-van Buul MM, Jansen J,<br />
Wouter ten Cate J, van Deventer SJ. Modulation <strong>of</strong> cytokine release<br />
and neutrophil function by granulocyte colony-stimulating factor<br />
during endotoxemia in humans. Blood 1997; 90: 1415-1424<br />
33 Zhang P, Bagby GJ, Stoltz DA, Summer WR, Nelson S.<br />
Enhancement <strong>of</strong> peritoneal leukocyte function by granulocyte<br />
colony-stimulating factor in rats with abdominal sepsis. Crit<br />
Care Med 1998; 26: 315-321<br />
S- Editor Liu Y L- Editor Roberts SE E- Editor Wang HF<br />
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www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
RAPID COMMUNICATION<br />
Study <strong>of</strong> the duodenal contractile activity during antral<br />
contractions<br />
Ahmed Shafik, Olfat El Sibai, Ali A Shafik<br />
Ahmed Shafik, Department <strong>of</strong> Surgery and Experimental<br />
Research, Faculty <strong>of</strong> Medicine, Cairo University, Cairo, Egypt<br />
Olfat El Sibai, Department <strong>of</strong> Surgery, Faculty <strong>of</strong> Medicine,<br />
Menoufia University, Shebin El-Kom, Egypt<br />
Ali A Shafik, Department <strong>of</strong> Surgery and Experimental Research,<br />
Faculty <strong>of</strong> Medicine, Cairo University, Cairo, Egypt<br />
Correspondence to: Ahmed Shafik, MD, PhD, Department <strong>of</strong><br />
Surgery and Experimental Research, Faculty <strong>of</strong> Medicine, Cairo<br />
University, 2 Talaat Harb Street, Cairo 11121,<br />
Egypt. shafik@ahmedshafik.com<br />
Telephone: +20-2-7498851 Fax: +20-2-7498851<br />
Received: 2007-02-13 Accepted: 2007-03-26<br />
Abstract<br />
AIM: To investigate the hypothesis that duodenal bulb (DB)<br />
inhibition on pyloric antrum (PA) contraction is reflex.<br />
METHODS: Balloon (condom)-tipped tube was<br />
introduced into 1 st duodenum (DD) and a manometric<br />
tube into each <strong>of</strong> PA and DD. Duodenal and antral<br />
pressure response to duodenal and then PA balloon<br />
distension with saline was recorded. These tests were<br />
repeated after separate anesthetization <strong>of</strong> DD and PA.<br />
RESULTS: Two and 4 mL <strong>of</strong> 1 st DD balloon distension<br />
produced no pressure changes in DD or PA (10.7 ± 1.2 vs<br />
9.8 ± 1.2, 11.2 ± 1.2 vs 11.3 ± 1.2 on H2O respectively,<br />
P > 0.05). Six mL distension effected 1 st DD pressure<br />
rise (30.6 ± 3.4 cm H2O, P < 0.01) and PA pressure<br />
decrease (6.2 ± 1.4 cm H2O, P < 0.05); no response<br />
in 2 nd , 3 rd and 4 th DD. There was no difference between<br />
6, 8, and 10 mL distensions. Ten mL PA distension<br />
produced no PA or 1 st DD pressure changes (P > 0.05).<br />
Twenty mL distension increased PA pressure (92.4 ±<br />
10.7 cm H2O, P < 0.01) and decreased 1 st DD pressure<br />
(1.6 ± 0.3 cm H 2O, P < 0.01); 30, 40, and 50 mL<br />
distension produced the same effect as the 20 mL<br />
distension (P > 0.05). PA or DD distension after separate<br />
anesthetization produced no significant pressure changes<br />
in PA or DD.<br />
CONCLUSION: Large volume DD distension produced<br />
DD pressure rise denoting DD contraction and PA pressure<br />
decline denoting PA relaxation. PA relaxation upon DD<br />
contraction is postulated to be mediated through a reflex<br />
which we call duodeno-antral reflex. Meanwhile, PA<br />
distension effected DD relaxation which we suggest to be<br />
reflex and termed antro-duodenal reflex. It is suggested<br />
that these 2 reflexes, could act as investigative tools in<br />
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diagnosis <strong>of</strong> gastroduodenal motility disorders.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Duodenal bulb; Gastroduodenal disorders;<br />
Reflex; Pyloric antrum; Motility<br />
Shafik A, El Sibai O, Shafik AA. Study <strong>of</strong> the duodenal<br />
contractile activity during antral contractions. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2600-2603<br />
http://www.wjgnet.com/1007-9327/13/2600.asp<br />
INTRODUCTION<br />
The stomach has two functions: secretion and motility.<br />
The main function <strong>of</strong> the proximal stomach is secretion,<br />
and so its motility pattern in the fed state takes the<br />
form <strong>of</strong> prolonged relaxation to delay intragastric food<br />
passage and provide ample time for contact with gastric<br />
enzymes [1-3] . The proximal stomach is <strong>of</strong>ten described<br />
as a receptive reservoir. Meanwhile the distal stomach<br />
functions to mechanically mix and crush the solid<br />
particles. Its motility pattern in the fed state presents a<br />
strong antral peristalsis that continues until complete<br />
evacuation <strong>of</strong> the chyme is achieved [1-3] . The antral<br />
peristalsis may be so strong as to raise the antral pressure<br />
to about 100 mm Hg [4] .<br />
The stomach and duodenum possess adaptive<br />
cytoprotection which represents an important defensive<br />
phenomenon [5] . However, this protection may be<br />
antagonized by drugs such as indomethacin. Nitric oxide<br />
increases HCO3-secretion in the duodenum. This action<br />
depends on cGMP- related COX-1 activation and is<br />
mediated by prostaglandins [6] .<br />
The antral mechanical contractions are believed to<br />
be under the control <strong>of</strong> a gastric pacemaker located at<br />
the junction <strong>of</strong> the upper with the lower two thirds <strong>of</strong><br />
the greater curvature [7] . In the fed state, the duodenal<br />
bulb contracts but, unlike the antrum, not continuously<br />
throughout the fed state. Duodenal bulb contractions cease<br />
intermittently to allow gastric emptying [7-9] . The mechanism<br />
<strong>of</strong> duodenal bulb inhibition upon antral contraction is<br />
not exactly known; is it a direct or reflex action between<br />
the antrum and duodenal bulb? We hypothesized that<br />
the mechanism <strong>of</strong> duodenal bulb relaxation upon antral<br />
contraction for gastric emptying is reflex. This hypothesis<br />
was investigated in the current study.
Shafik A et al . Antro-duodenal reflexes 2601<br />
MATERIALS AND METHODS<br />
Subjects<br />
Thirty-two healthy volunteers (mean age 38.2 ± 9.7 SD,<br />
range 27-48, 20 men, 12 women) were enrolled in the study<br />
after giving informed written consent. The subjects were<br />
selected to have no gastrointestinal complaint in the past<br />
or at the time <strong>of</strong> enrollment. Physical examination, including<br />
neurological assessment, was normal. The results <strong>of</strong><br />
examination <strong>of</strong> blood count, renal and hepatic functions as<br />
well as electrocardiography were unremarkable. Endoscopies<br />
for esophagus, stomach, and duodenum showed normal<br />
findings. The study was approved by the Review Board<br />
and Ethics Committee <strong>of</strong> the Cairo University Faculty <strong>of</strong><br />
Medicine.<br />
Methods<br />
The subjects fasted for 12 h. A condom was applied to the<br />
distal end <strong>of</strong> a Ryle stomach tube (8 French, Pharma Plast<br />
Int AS/DK 3540, Lynge, Denmark) containing multiple<br />
lateral apertures. One tie was applied at each end <strong>of</strong> the<br />
condom to fashion a high compliance balloon. A silver<br />
clip was applied to the distal end <strong>of</strong> the tube for radiologic<br />
control. A mechanical puller was used for automatic tube<br />
withdrawal (9021 H, Disa, Copenhagen). The tube with<br />
the empty condom was swallowed by the volunteers and<br />
the condom was directed to lie in the 1st part <strong>of</strong> the<br />
dudodenum (DD). The tube was connected to a strain<br />
gauge pressure transducer (Statham 230B, Oxnard, CA,<br />
USA).<br />
Simultaneous measurement <strong>of</strong> the pressure in the<br />
PA and DD was performed by means <strong>of</strong> a perfused<br />
open-ended tube <strong>of</strong> 1 mm internal and 1.5 mm external<br />
diameter. One tube was introduced into each <strong>of</strong> the<br />
PA and 1 st DD. Each tube was connected to a Statham<br />
pressure transducer. The position <strong>of</strong> these manometric<br />
tubes was accurately determined from the previously<br />
performed barium enemas and from the fluoroscopic<br />
screening. For the latter, a silver clip had been applied to<br />
the distal end <strong>of</strong> each tube. The pressure recordings were<br />
performed 20 min after tubal positioning so that the gut<br />
could have adapted to the presence <strong>of</strong> the tubes.<br />
The resting (basal) pressure was recorded in the PA<br />
and in each <strong>of</strong> the 4 parts <strong>of</strong> the DD. The condom, while<br />
lying in the 1 st DD, was filled in increments <strong>of</strong> 2 mL up<br />
to 10 mL and the pressure in the PA and the 1 st DD was<br />
recorded at each <strong>of</strong> the volumes. The condom was then<br />
emptied and placed successively in the 2 nd , 3 rd , and 4 th parts<br />
<strong>of</strong> the DD, and the aforementioned test was repeated. The<br />
emptied condom was then pulled under guidance <strong>of</strong> the<br />
screen to lie in the PA as was confirmed under the screen.<br />
It was filled with normal saline in increments <strong>of</strong> 10 mL<br />
up to 50 mL and the pressure in the PA and 1 st DD was<br />
recorded at each <strong>of</strong> the volumes. The test was repeated<br />
while the manometric tube was managed to lie successively<br />
in the 2 nd , 3 rd , and 4 th DD. For fear <strong>of</strong> antral or duodenal<br />
injury, we did not fill the condom with saline quantities<br />
beyond the mentioned volumes.<br />
The effect <strong>of</strong> antral and duodenal anesthetization on the<br />
duodenal pressure<br />
The effect <strong>of</strong> distension <strong>of</strong> the anesthetized DD on the<br />
A<br />
B<br />
C<br />
DD<br />
PA pressure was examined. The DD was anesthetized by<br />
instilling 10 mL <strong>of</strong> 2 percent <strong>of</strong> lidocaine through the<br />
tube placed in the DD. The PA response to distension <strong>of</strong><br />
the anesthetized DD was determined after 20 min and 2 h<br />
later when the anesthetic effect had waned. The test was<br />
repeated using normal saline instead <strong>of</strong> lidocaine. After 2 d,<br />
the response <strong>of</strong> the DD pressure to distension <strong>of</strong> the<br />
anesthetized PA was recorded. The PA was anesthetized<br />
by means <strong>of</strong> 50 mL <strong>of</strong> 2 percent lidocaine instilled<br />
through the tube in the PA. The effect <strong>of</strong> distension <strong>of</strong><br />
the anesthetized PA on the DD was registered after 20 min<br />
and again after 2 h <strong>of</strong> anesthetization. The test was<br />
repeated using normal saline instead <strong>of</strong> lidocaine.<br />
To ensure reproducibility <strong>of</strong> the results, the aforementioned<br />
recordings were repeated at least twice in the<br />
individual subject and the mean value was calculated. The<br />
results were analyzed statistically using the Student’s t test<br />
and values were given as the mean ± SD. Differences<br />
assumed significance at P < 0.05.<br />
RESULTS<br />
PA ←<br />
DD<br />
PA<br />
DD<br />
PA<br />
←<br />
←<br />
20 cm H2O<br />
10 S<br />
20 cm H2O<br />
10 S<br />
20 cm H2O<br />
10 S<br />
Figure 1 Response <strong>of</strong> the duodenum and pyloric antrum to 2 mL (A), 6 mL (B),<br />
and 10 mL (C) duodenal balloon distension with normal saline. ↑: Duodenal<br />
balloon distension.<br />
The study was completed in all <strong>of</strong> the subjects with no<br />
adverse side effects. The mean resting pressure in the PA<br />
was 11.2 ± 1.2 cm H2O (range 10-13), and in the 1 st DD<br />
10.7 ± 1.2 cm H2O (range 9-12); the pressure <strong>of</strong> the 2 nd ,<br />
3 rd , and 4 th DD was similar to that <strong>of</strong> the 1 st DD (P > 0.05).<br />
Response <strong>of</strong> the DD and PA pressures to duodenal<br />
balloon distension. Duodenal balloon distension with 2<br />
and 4 mL <strong>of</strong> normal saline effected no significant pressure<br />
changes to the 4 duodenal parts or the PA (P > 0.05,<br />
Figure 1A). The duodenal pressure recorded a mean <strong>of</strong><br />
9.8 ± 1.2 cm H 2O (range 8-12) with no significant<br />
differences in the 4 duodenal segments, and the PA a mean<br />
<strong>of</strong> 11.3 ± 1.2 cm H2O (range 10-13). Meanwhile 6 mL<br />
balloon distension <strong>of</strong> the 1 st DD produced a significant<br />
duodenal pressure elevation and a PA pressure decrease<br />
(Figure 1B); no significant pressure changes occurred<br />
in the 2 nd , 3 rd , and 4 th DD. The pressure in the 1 st DD<br />
recorded a mean <strong>of</strong> 30.6 ± 3.4 cm H2O (range 26-34, P <<br />
0.01) and the PA pressure 6.2 ± 1.4 cm H2O (range 4-8, P<br />
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2602 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
A<br />
B<br />
C<br />
DD<br />
PA<br />
DD<br />
PA<br />
DD<br />
PA ←<br />
←<br />
←<br />
20 cm H2O<br />
10 S<br />
20 cm H2O<br />
10 S<br />
20 cm H2O<br />
10 S<br />
Figure 2 Response <strong>of</strong> pyloric antrum and duodenum to 10 mL (A), 20 mL (B), and<br />
50 mL (C) antral balloon distension with normal saline. ↑: Antral balloon distension.<br />
< 0.05), and the balloon was dispelled to the 2 nd DD; the<br />
2 nd , 3 rd , and 4 th parts <strong>of</strong> the DD recorded a mean <strong>of</strong> 10.2 ±<br />
1.2 cm H2O (range 9-12, P > 0.05). Balloon distension <strong>of</strong><br />
the 1 st DD with 8 and 10 mL <strong>of</strong> saline produced duodenal<br />
and PA pressure changes similar to the 6 mL balloon<br />
distension (P > 0.05, Figure 1C).<br />
Response <strong>of</strong> the PA and DD pressures to pyloric antral<br />
balloon distension. Pyloric antral distension with 10 mL <strong>of</strong><br />
saline did not effect significant pressure changes in the PA (P<br />
> 0.05) or the 1 st , 2 nd , 3 rd , and 4 th DD (P > 0.05, Figure 2A).<br />
The PA pressure recorded a mean <strong>of</strong> 10.9 ± 1.2 cm H2O<br />
(range 10-13). The duodenal pressure recorded a mean <strong>of</strong><br />
10.3 ± 1.2 cm H2O (range 8-12) in the four segments <strong>of</strong> the<br />
DD with no significant difference in the pressure response<br />
between them. Twenty mL balloon distension <strong>of</strong> the PA<br />
produced a significant increase <strong>of</strong> the PA pressure and a<br />
decrease <strong>of</strong> the 1 st DD pressure, so that the balloon was<br />
dispelled to the 1 st DD (Figure 2B); no significant pressure<br />
changes occurred in the remaining 3 DD segments. The 1 st<br />
DD recorded a mean pressure <strong>of</strong> 1.6 ± 0.3 cm H2O (range<br />
1-2.4, P < 0.01) and the other 3 parts <strong>of</strong> the DD a mean<br />
<strong>of</strong> 10.6 ± 1.2 (range 8-12, P > 0.05, Figure 2B). The PA<br />
pressure recorded a mean <strong>of</strong> 92.4 ± 10.7 cm H2O (range<br />
81-108, P < 0.01). Pyloric antral balloon distension with 30,<br />
40, and 50 mL <strong>of</strong> normal saline produced pressure changes<br />
in the DD and PA similar to those produced by the 20 mL<br />
distension (P > 0.05, Figure 2C).<br />
Response <strong>of</strong> the duodenal pressure to distension <strong>of</strong> the<br />
anesthetized PA and DD<br />
Twenty minutes after the DD or PA had been separately<br />
anesthetized, saline balloon distension <strong>of</strong> either with up<br />
to 10 mL in the DD and 50 mL in the PA resulted in<br />
no significant pressure changes in the DD (P > 0.05).<br />
Two hours later when the anesthetic effect had waned,<br />
duodenal or antral balloon distension effected DD pressure<br />
responses similar to those prior to anesthetization (P > 0.05).<br />
Distension <strong>of</strong> the saline-containing DD or PA induced a<br />
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DD pressure response similar to that recorded without the<br />
use <strong>of</strong> saline (P > 0.05).<br />
The aforementioned results were reproducible with<br />
no significant difference (P > 0.05) when the tests were<br />
repeated in the individual subject.<br />
DISCUSSION<br />
The current study could shed some light on the response<br />
<strong>of</strong> the DD to the chyme bolus delivery from the PA. After<br />
the gastric content in the PA has been triturated to small<br />
particles, the PA contracts, the pyloric sphincter relaxes,<br />
and the chyme is passed to the DD [10-12] . The present<br />
investigation has shown that the PA did not respond to<br />
small chyme volumes; small volume balloon distension<br />
<strong>of</strong> the PA did not effect pressure changes in the PA or 1 st<br />
DD. Meanwhile, large volumes <strong>of</strong> pyloric antral distension<br />
produced a significant PA pressure increase and a 1 st<br />
DD pressure decrease, which presumably denotes PA<br />
contraction and DD relaxation; however, the rest <strong>of</strong> the<br />
DD exhibited no pressure changes. Thus, it appears that<br />
the 1 st DD relaxes upon PA contraction, provided the PA<br />
distension is effected by a large bolus. The 1 st DD seems<br />
to relax to accommodate the delivered bolus.<br />
The study has also demonstrated that a large volume<br />
balloon distension <strong>of</strong> the DD produced increase <strong>of</strong> the<br />
duodenal pressure and decrease <strong>of</strong> the PA pressure. This<br />
presumably denotes that a large bolus entering the 1 st DD<br />
causes DD contraction and PA relaxation. PA relaxation<br />
seems to prepare the PA for receiving new food boli for<br />
grinding, while 1 st DD contraction delivers the chyme<br />
to the remaining DD segments hence become clear<br />
for receiving the following food bolus. Thus, it appears<br />
that during food digestion in the stomach, the chyme is<br />
transmitted to the DD through cycles <strong>of</strong> PA contraction<br />
and 1 st DD relaxation followed by DD contraction and<br />
PA relaxation. These cycles <strong>of</strong> successive contraction and<br />
relaxation <strong>of</strong> the PA and DD and vice versa apparently<br />
continue until the stomach evacuates its contents.<br />
The question that needs to be addressed is the PA<br />
relation to the 1 st DD: is it a direct or reflex relationship?<br />
Duodeno-antral and antro-duodenal reflexes<br />
Relaxation <strong>of</strong> the PA upon DD contraction postulates a<br />
reflex relationship between the 2 actions. This relationship<br />
was reproducible and its reflex nature is evidenced by its<br />
absence on individual anesthetization <strong>of</strong> the assumed two<br />
arms <strong>of</strong> the reflex arc, namely the PA or DD. We call this<br />
reflex relationship the ‘duodeno-antral reflex’ (DAR). This<br />
reflex apparently functions to relax the PA preparatory to<br />
receiving the next bolus <strong>of</strong> gastric contents for grinding;<br />
meanwhile contraction <strong>of</strong> the 1 st DD pushes its contents<br />
to the remaining 3 DD segments, which eventually clears<br />
the 1 st DD to receive new chyme boli. The current study<br />
further demonstrates that the 1 st DD relaxes on PA<br />
contraction. This relationship was also reproducible, and<br />
its suggested reflex nature is evidenced by its absence on<br />
anesthetization <strong>of</strong> the 2 arms <strong>of</strong> the reflex arc: PA or DD.<br />
We call this reflex relationship the ‘antro-duodenal reflex’<br />
(ADR). The 1 st DD presumably relaxes to receive the
Shafik A et al . Antro-duodenal reflexes 2603<br />
chyme from the contracting PA.<br />
Balloon distension <strong>of</strong> the PA or 1 st DD apparently<br />
stimulates the antral or duodenal mechanoreceptors.<br />
Nerve impulses are transmitted to the spinal cord which<br />
sends impulses to the PA or DD. Anesthetization <strong>of</strong> the<br />
PA or DD seems to block their innervation so that nerve<br />
impulses cannot be transmitted to the spinal cord. Lidocaine<br />
blocks the sensory fibers (C and A α-fibers) which are<br />
responsible for pain and reflex activity [13-14] . Whether these<br />
reflex impulses are transmitted via extrinsic or intrinsic<br />
nerves needs further studies. However, investigators have<br />
recently reported on the effect <strong>of</strong> intraduodenal capsaicin<br />
on the interdigestive gastric contractions [15] . They found that<br />
duodenal afferent fibers stimulated by capsaicin inhibited the<br />
gastric contraction via a nitric oxide-independant extrinsic<br />
neural factor.<br />
Diagnostic role <strong>of</strong> the DAR and ADR<br />
These 2 reflexes may prove to be <strong>of</strong> diagnostic significance<br />
in gastroduodenal motile disorders. Detectable changes<br />
in the DD reflex response to PA distension or <strong>of</strong> the PA<br />
to DD distension might denote a motility disorder <strong>of</strong> the<br />
PA or DD, or both. The reflex may thus be included as<br />
an investigative tool in the diagnosis <strong>of</strong> motility disorders<br />
in the gastroduodenum, provided further studies are<br />
performed in this respect.<br />
In conclusion, the study has demonstrated the relaxation<br />
<strong>of</strong> the PA on duodenal contraction, and DD relaxation on<br />
PA contraction. This effect between the PA and the DD<br />
appears to be mediated through two reflexes which we call<br />
the ‘duodeno-antral’ and the ‘antro-duodenal’ reflexes. These<br />
reflexes seem to allow the chyme to pass to the 1 st DD<br />
and from the latter to the rest <strong>of</strong> the DD. Further studies<br />
are required to investigate the functional and diagnostic<br />
significance <strong>of</strong> these 2 reflexes.<br />
ACKNOWLEDGMENTS<br />
Margot Yehia assisted in preparing the manuscript.<br />
REFERENCES<br />
1 Kelly KA. Gastric emptying <strong>of</strong> liquids and solids: roles <strong>of</strong><br />
proximal and distal stomach. Am J Physiol 1980; 239: G71-G76<br />
2 Houghton LA, Read NW, Heddle R, Maddern GJ, Downton J,<br />
Toouli J, Dent J. Motor activity <strong>of</strong> the gastric antrum, pylorus,<br />
and duodenum under fasted conditions and after a liquid<br />
meal. <strong>Gastroenterology</strong> 1988; 94: 1276-1284<br />
3 Brown BP, Schulze-Delrieu K, Schrier JE, Abu-Yousef MM.<br />
The configuration <strong>of</strong> the human gastroduodenal junction in<br />
the separate emptying <strong>of</strong> liquids and solids. <strong>Gastroenterology</strong><br />
1993; 105: 433-440<br />
4 Quigley EM, Donovan JP, Lane MJ, Gallagher TF. Antroduodenal<br />
manometry. Usefulness and limitations as an outpatient study.<br />
Dig Dis Sci 1992; 37: 20-28<br />
5 Mise S, Tonkic A, Pesutic V, Tonkic M, Mise S, Capkun V,<br />
Batelja L, Blagaic AB, Kokic N, Zoricic I, Saifert D, Anic T,<br />
Seiwerth S, Sikiric P. The presentation and organization <strong>of</strong><br />
adaptive cytoprotection in the rat stomach, duodenum, and<br />
colon. Dedicated to Andre Robert the founder <strong>of</strong> the concept<br />
<strong>of</strong> cytoprotection and adaptive cytoprotection. Med Sci Monit<br />
2006; 12: BR146-BR153<br />
6 Furukawa O, Kawauchi S, Mimaki H, Takeuchi K. Stimulation<br />
by nitric oxide <strong>of</strong> HCO3-secretion in bullfrog duodenum in<br />
vitro--roles <strong>of</strong> cyclooxygenase-1 and prostaglandins. Med Sci<br />
Monit 2000; 6: 454-459<br />
7 Sanders KM, Vogalis F. Organization <strong>of</strong> electrical activity in<br />
the canine pyloric canal. J Physiol 1989; 416: 49-66<br />
8 Brophy CM, Moore JG, Christian PE, Egger MJ, Taylor<br />
AT. Variability <strong>of</strong> gastric emptying measurements in man<br />
employing standardized radiolabeled meals. Dig Dis Sci 1986;<br />
31: 799-806<br />
9 Lin HC, Meyer JH. Disorders <strong>of</strong> gastric emptying. In: Yamada<br />
T. Textbook <strong>of</strong> <strong>Gastroenterology</strong>. Philadelphia: JB Lippincott<br />
Co, 1991; 1213-1240<br />
10 Cooke AR. Control <strong>of</strong> gastric emptying and motility.<br />
<strong>Gastroenterology</strong> 1975; 68: 804-816<br />
11 McCallum RW. Motor function <strong>of</strong> the stomach in health<br />
and disease. In: Sleisenger MH, Fordtran JS. Gastrointestinal<br />
Disease: Pathophysiology, Diagnosis, Management.<br />
Philadelphia: Saunders, 1989; 675-713<br />
12 Treacy PJ, Dent J, Jamieson GC. Antropyloric pressure<br />
and isolated pyloric waves are major regulators <strong>of</strong> gastric<br />
emptying <strong>of</strong> liquids. <strong>Gastroenterology</strong> 1988; 94: 464-468<br />
13 Yokoyama O, Komatsu K, Kodama K, Yotsuyanagi S, Niikura<br />
S, Namiki M. Diagnostic value <strong>of</strong> intravesical lidocaine for<br />
overactive bladder. J Urol 2000; 164: 340-343<br />
14 Silva C, Ribeiro MJ, Cruz F. The effect <strong>of</strong> intravesical<br />
resiniferatoxin in patients with idiopathic detrusor instability<br />
suggests that involuntary detrusor contractions are triggered<br />
by C-fiber input. J Urol 2002; 168: 575-579<br />
15 Shibata C, Naito H, Ueno T, Jin XL, Funayama Y, Fukushima K,<br />
Matsuno S, Sasaki I. Intraduodenal capsaicin inhibits gastric<br />
migrating motor complex via an extrinsic neural reflex in<br />
conscious dogs. Neurogastroenterol Motil 2002; 14: 543-551<br />
S- Editor Liu Y L- Editor Alpini GD E- Editor Chen GJ<br />
www.wjgnet.com
Feng Y et al . Protein analysis <strong>of</strong> cell line SMMC-7721 2609<br />
status <strong>of</strong> tissues and cells. In the comprehensive proteomics,<br />
all the expressed proteins are discovered and counted.<br />
The comprehensive proteomics is not only the basis for<br />
acquiring the global protein pr<strong>of</strong>iles, but also is significant to<br />
the exploratory research <strong>of</strong> proteins interrelations and the<br />
related metabolic processes.<br />
The genesis and growth <strong>of</strong> HCC is complexly and multifactorially<br />
regulated, so it is regarded that several candidate<br />
proteins may be involved in this process. To find and<br />
identify these candidate proteins, a technology which can<br />
screen out the candidate proteins and then acquire their<br />
abundant information is needed. Associated with internet<br />
query from the related databases, proteomic methods,<br />
especially consisting <strong>of</strong> two-dimensional electrophoresis<br />
(2DE) and the subsequent mass spectrometry (MS), are<br />
available to analyze the candidate proteins related to HCC<br />
genesis and growth. These identified proteins can also<br />
become the novel biomarkers for the prediction, diagnosis<br />
and therapy <strong>of</strong> HCC.<br />
Some studies on the comparative proteomic analysis<br />
<strong>of</strong> HCC focus on the novel biomarkers identification for<br />
the HCC pathogenesis, diagnosis and therapy. Persistent<br />
viral infections, mainly including hepatitis B viruses (HBV)<br />
or hepatitis C viruses (HCV) infection [1] , are regarded as<br />
the main etiological factors <strong>of</strong> HCC. The chronic liver<br />
injuries, including inflammation, regeneration, fibrosis<br />
and cirrhosis which are resulted from hepatitis viral<br />
infections, are always preformed to HCC too. To get the<br />
candidate biomarkers related to the potential etiological<br />
factors <strong>of</strong> HCC, proteomic analyses were performed<br />
with the cirrhosis [2] , HBV [3] and HCV-associated [4,5] HCC,<br />
and various differently expressed proteins related to the<br />
etiological factors were identified. Additionally, some <strong>of</strong><br />
them were suggested to be candidate biomarkers for HCC<br />
diagnosis and therapy.<br />
Other proteomic analyses <strong>of</strong> HCC pay attention<br />
to the comprehensive identification <strong>of</strong> proteins in the<br />
hepatocarcinoma cell lines. The comprehensive protein<br />
identification in hepatocarcinoma cell lines can give<br />
abundant information about the characteristics <strong>of</strong><br />
expressed proteins in hepatocarcinoma cells, and then<br />
help to analyze the interrelations <strong>of</strong> the expressed proteins<br />
and the specific functions <strong>of</strong> the identified proteins in the<br />
cancer-related metabolic processes. Proteins expressed in<br />
various hepatocarcinoma cell lines, including BEL7404 [6] ,<br />
HepG2 [7,8] and HCC-M [9] , have been identified. And a few<br />
proteins or protein families are pointed out to be cancerrelated;<br />
meanwhile the associated metabolic processes are<br />
also suggested in these studies. Prohibitin, calreticulin and<br />
some members <strong>of</strong> heat-shock protein family, which are<br />
identified in the present study, are also introduced in these<br />
studies.<br />
To our knowledge, there has not been the comprehensive<br />
proteomic analysis <strong>of</strong> SMMC-7721 cells so far. Only in<br />
the study on all-trans retinoic acid (ATRA)-inhibited cell<br />
proliferation and migration <strong>of</strong> SMMC-7721 cell line, the<br />
comparative proteomic analysis <strong>of</strong> SMMC-7721 cells was<br />
performed to find the different expressed proteins after<br />
the ATRA treatment [10] ; however, the comprehensive<br />
proteomic analysis is not included. Hepatocarcinoma cell<br />
line SMMC-7721 is established from a Chinese HCC patient<br />
and is commonly used in the research <strong>of</strong> HCC in China.<br />
Anticancer effects and mechanisms <strong>of</strong> different anti-cancer<br />
drugs, including adriamycin (ADR) [11] , paclitaxel (PTX) [12]<br />
and docetaxel (Taxotere ® ) [13] , etc., have been experimented<br />
on SMMC-7721 cell line. The physical and chemical<br />
factors, such as oxidative stress [14] , free radical, heat-therapy,<br />
ultraviolet radiation, and chemical reagents, could act on<br />
SMMC-7721 cells and change their growing status. These<br />
physical and chemical factors, combined with suitable<br />
clinical schemes, were then introduced to the new methods<br />
for HCC prevention and therapy. SMMC-7721 cells were<br />
also used to evaluate the targeted and binding efficiency <strong>of</strong><br />
the targeted drug delivery system and the anti-human HCC<br />
monoclonal antibody [15] .<br />
In the present work, proteins from hepatocarcinoma<br />
cell line SMMC-7721 were well separated by 2DE and<br />
identified by peptide mass fingerprinting based on<br />
MALDI-TOF-MS. Among 21 successfully identified<br />
proteins, six were found to be the novel proteins in the<br />
cells or tissues from HCC. Specific functions <strong>of</strong> the<br />
identified proteins were analyzed and their potential<br />
contribution to the pathogenesis and development <strong>of</strong><br />
HCC were explored. The results are useful to study on<br />
HCC pathogenesis, and to give support to establish the<br />
effective diagnostic and therapeutic schemes.<br />
MATERIALS AND METHODS<br />
Chemicals and materials<br />
Immobilized pH gradient (IPG) strips (pH 3-10,<br />
nonlinear, 13 cm) and IPG buffer (pH 3-10, nonlinear)<br />
were purchased from Pharmacia, Amersham Biotech.<br />
Dithiothreitol (DTT), PMSF and CHAPS were purchased<br />
from Sigma Company (USA). All the buffers were made<br />
by using high purity MilliQ water. IPGphor isoelectric<br />
focusing equipment, Hoefer SE 600 vertical chambers,<br />
electrophoresis apparatus, and Image Master 2D Elite<br />
4.01 s<strong>of</strong>tware were purchased from Pharmacia, Amersham<br />
Biotech. Voyager-DE MALDI-TOF MS was product <strong>of</strong><br />
Applied Biosystems (USA).<br />
SMMC-7721 cell line culture and sample collection<br />
The human hepatocarcinoma cell line SMMC-7721 was<br />
supplied by the Center <strong>of</strong> Laboratory Animals <strong>of</strong> the Forth<br />
Military Medical University, China. SMMC-7721 cells were<br />
cultured in RPMI 1640 culture medium, and were generated<br />
once in every two days. After five generations, every two<br />
flasks <strong>of</strong> cells were collected into one 1 mL-eppendorf<br />
tube after being centrifuged at 1000 × g for 5 min and<br />
then resuspended with cooled PBS. The suspended cells<br />
were washed with cooled PBS for 3 times and then were<br />
centrifuged at 1500 × g for 10 min to get the cell pellet.<br />
The supernatant was abandoned carefully and the pellet in<br />
eppendorf tube was stored in -80℃ ultra low temperature<br />
freezer (LegaciTM Refregeration system, REVCO<br />
Technologies) for the subsequent 2D PAGE analysis. All the<br />
processes were performed in sterile condition.<br />
Sample prepared for 2D-PAGE<br />
Before cell lysis, cooled and distilled water was used to<br />
rinse the surface <strong>of</strong> cell pellets gently for two times to<br />
www.wjgnet.com
2610 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Mw<br />
97K<br />
66K<br />
43K<br />
31K<br />
20K<br />
P11021<br />
P07237<br />
P27797<br />
P07437<br />
P06576<br />
P08670<br />
P02570<br />
Figure 1 Two-dimensional electrophoresis map <strong>of</strong> human hepatocarcinoma cell<br />
line SMMC-7721.<br />
remove the remnant phosphate. For two bottles <strong>of</strong> cells,<br />
100 μL <strong>of</strong> lysis solution containing 8 mol/L urea, 40 g/L<br />
CHAPS and 20 g/L Pharmalyte 3-10 was added into the<br />
eppendorf tube, and well-established freeze-thaw lysis<br />
method was used to extract the proteins from SMMC-7721<br />
cells with added 0.1 mmol/L PMSF as protease inhibitor.<br />
Then the suspension was centrifuged at 40 000 × g for 1 h<br />
at 4℃ (Beckman TL100 Ultracentrifuge, TLA 100.3 rotor,<br />
Fullerton, CA, USA). All the process was carried through<br />
in ice bath or at 4℃. The precipitation was removed and<br />
the supernatant was retained for the subsequent 2D-PAGE<br />
analysis. Protein concentration was measured by the<br />
Bradford assay using bovine serum albumin as standard.<br />
First dimension: Isoelectric focusing<br />
Proteins were isoelectr<strong>of</strong>ocused on the IPGphor isoelectric<br />
focusing equipment. Extracted protein was mixed with<br />
reswelling buffer (8 mol/L urea, 20 g/L CHAPS, 0.7 mg<br />
DTT, 1 μL IPG buffer 3-10 and 0.02 g/L bromophenol<br />
blue). The mixture was oscillated completely by Vortex<br />
Mixer and centrifuged at 2000 × g for 2 min at 4℃ to<br />
remove the foam. Then 250 μL <strong>of</strong> supernatant (containing<br />
200 μg proteins) was added in the ceramic strip holder<br />
and IPG strip was placed in it with Mineral oil (Pharmacia,<br />
Amersham Biotech) covered. The dried IPG strips were<br />
rehydrated for 12 h with the sample in reswelling buffer<br />
(250 μL) in the ceramic strip holder (1 h without current,<br />
followed by 5 h at 30 V and then 6 h at 60 V). After<br />
rehydration for 12 h, protein samples were focused at 200 V<br />
for 3 h and 500 V for 3 h to remove any ions contained,<br />
and then for 30 min each at 1000 V, 5000 V and 8000 V,<br />
respectively, followed by 8000 V, for a total <strong>of</strong> 35 000 Vhs.<br />
Second dimension: SDS-PAGE<br />
IPG strips were removed into the first equilibrated<br />
buffer (50 mmol/L Tris-HCl, 6 mol/L urea, 20 g/L<br />
SDS, 300 mL/L glycerol, 30 mmol/L DTT, pH 6.8) and<br />
incubated for 15 min after isoelectric focusing, followed by<br />
incubation in the second equilibrated buffer (50 mmol/L<br />
Tris-HCl, 6 mol/L urea, 20 g/L SDS, 300 mL/L glycerol,<br />
25 g/L iodoacetamide, pH 6.8) for 15 min. After twosteps<br />
equilibration, IPG strips were loaded on the 2D gels<br />
(14 cm × 15 cm, 1 mm thickness) which contained 120 g/<br />
www.wjgnet.com<br />
3.0 10.0<br />
Q13011<br />
P35232<br />
P30081<br />
P30040<br />
Q13162<br />
32483377<br />
Q16891<br />
P02545<br />
P38646<br />
P02545<br />
P10809<br />
P30101<br />
P55809<br />
P31930<br />
P21796<br />
L acrylamide and were sealed by 5 g/L agarose containing<br />
0.02 g/L bromophenol blue. The second dimension<br />
separation was performed using Hoefer SE 600 standard<br />
vertical system with the current <strong>of</strong> 10 mA per strip for<br />
20 min, followed by 20 mA per strip for 5 h. The 2D<br />
gels were stained using optimized classic silver staining<br />
method which is more suitable for mass spectrometry<br />
identification.<br />
Analysis <strong>of</strong> 2D gel images<br />
The 2D gel images were acquired from a Sharp JX-330<br />
scanner and analyzed by the Image Master 2D Elite<br />
s<strong>of</strong>tware. After intensity calibration, spot detection,<br />
background subtraction, normalization and one dimension<br />
calibration, the pI and molecular weight <strong>of</strong> each spot<br />
were calculated, followed by the identification based on<br />
MALDI-TOF-MS.<br />
Identification <strong>of</strong> proteins using MALDI-TOF-MS<br />
The selected protein spots were cut from the gel and<br />
tryptic digested in gel. The extracted enzymolyzed peptides<br />
were identified by peptide mass fingerprinting based on<br />
matrix-assisted laser desorption/ionization time-<strong>of</strong>-flight<br />
mass spectrometry (MALDI-TOF-MS, Voyager-DE),<br />
analyzed using Data explore (Applied Biosystems) and<br />
matched in ProFound-Peptide Mapping (http://prowl.<br />
rockefeller.edu/pr<strong>of</strong>ound_bin/WebProFound.exe).<br />
RESULTS<br />
2D-PAGE analysis<br />
The representative examples <strong>of</strong> cell proteins separated<br />
on a 2D-gel are shown in Figure 1, where 200 μg <strong>of</strong> total<br />
proteins extracted from SMMC-7721 cells were loaded.<br />
Nearly 1000 proteins spots were obtained in the range <strong>of</strong><br />
Mr 14.4-94.0 kDa, pI 3-10. We successfully identified 21<br />
proteins and marked in this map with their NCBI/SWISS-<br />
PROT number. The 2D map shows that there are various<br />
proteins abundantly expressed in the high molecular mass<br />
region at acidic end and this characteristic appears in all the<br />
2D gels with different protein sample load. The different<br />
lysis solutions (7 mol/L urea, 2 mol/L thiourea, 40 g/L<br />
CHAPS, 60 mmol/L DTT, 20 g/L Pharmalyte pH 3-10<br />
and 0.02 g/L bromophenol blue) led to a few changes <strong>of</strong><br />
protein pr<strong>of</strong>ile at basic end; however, no change in the<br />
high expression <strong>of</strong> proteins in high molecular mass region<br />
at acidic end.<br />
Protein identification by MS<br />
The information <strong>of</strong> proteins marked in Figure 1 are<br />
shown in Table 1, including the theoretical pI/Mr (kDa)<br />
value <strong>of</strong> identified proteins from Pr<strong>of</strong>ound, experimental<br />
pI/Mr (kDa) value from one-dimensional calibration <strong>of</strong><br />
2D image in Image Master 2D Elite, Pr<strong>of</strong>ound scores and<br />
normalization volume. Comparison between experimental<br />
and theoretical pI/Mr (kDa) <strong>of</strong> proteins was used to<br />
ensure the protein identification based on the MS results.<br />
The Pr<strong>of</strong>ound score represented the possibility <strong>of</strong> correct<br />
identification in ProFound-Peptide mapping. score <strong>of</strong> 1.65<br />
for a search means that the search was in the 95 th percentile,
Feng Y et al . Protein analysis <strong>of</strong> cell line SMMC-7721 2613<br />
expression <strong>of</strong> prohibitin may be a reciprocal indicator for<br />
the inhibition <strong>of</strong> cell proliferation or be related to other<br />
interaction <strong>of</strong> prohibitin with various cell-cycle regulatory<br />
proteins rather than inducing anti-proliferation.<br />
The identified proteins in the present study may<br />
be involved in the tumorigenesis, tumor growth and<br />
metastasis <strong>of</strong> hepatocarcinoma via their own way and<br />
some <strong>of</strong> them may be the candidate biomarkers for<br />
hepatocarcinoma diagnosis and therapy. However, some<br />
proteins also exist in normal liver cells and may behave<br />
different functions during the carcinogenesis in tumor<br />
cells or tissues compared with in normal ones. Thus, the<br />
expression <strong>of</strong> these proteins in normal and tumor tissues<br />
need to be examined and compared further, and the<br />
cloning and functional studies need to be carried out to<br />
ensure whether these proteins are significantly involved in<br />
the process <strong>of</strong> carcinogenesis.<br />
COMMENTS<br />
Background<br />
In the processes <strong>of</strong> hepatocarcinoma genesis, growth and metastasis, proteins<br />
are always the main participators involved. So, to get the protein pr<strong>of</strong>ile <strong>of</strong><br />
hepatocarcinoma cells or tissues would give us useful information to analyze the<br />
protein interactions happened, as well as how the physiological or pathological<br />
metabolic processes are activated and developed. Proteomic analysis, based on<br />
two-dimensional electrophoresis and MALDI-TOF mass spectrometry, is a useful<br />
tool to analyze protein functions in the tumor cells or tissues.<br />
Research frontiers<br />
The present study gives the protein pr<strong>of</strong>ile <strong>of</strong> human hepatocarcinoma cell line<br />
SMMC-7721. Based on the functional information <strong>of</strong> proteins identified, their<br />
potential involvements in the process <strong>of</strong> hepatocarcinoma genesis, development<br />
and metastasis are presumably suggested.<br />
Innovations and breakthroughs<br />
Some previous studies gave the comprehensive proteomic analysis <strong>of</strong> other<br />
human hepatocarcinoma cell lines. The present study shows the protein pr<strong>of</strong>ile <strong>of</strong><br />
human hepatocarcinoma cell line SMMC-7721 and finds six novel proteins which<br />
have never been reported before in the liver cancer cells or tissues. The functions<br />
<strong>of</strong> identified proteins are also analyzed, which suggest their involvements in the<br />
tumor pathogenesis and development.<br />
Applications<br />
The present study would help better analysis <strong>of</strong> hepatocarcinoma development,<br />
which can promote new therapeutic schemes. Further comparison with normal<br />
liver cells or tissues can give more useful information.<br />
Peer review<br />
The current manuscript describes a comprehensive proteomics analysis <strong>of</strong><br />
the hepatocarcinoma cell line SMMC-7721. Six novel proteins in the setting<br />
<strong>of</strong> hepatocellular carcinoma were identified. My main criticism with regard to<br />
the approach <strong>of</strong> the authors is that they did not use proteins <strong>of</strong> normal human<br />
hepatocytes as reference material. It is clearly significantly more informative to<br />
know to which extent a protein expression pr<strong>of</strong>ile differs from normal cells.<br />
REFERENCE<br />
1 Seow TK, Liang RC, Leow CK, Chung MC. Hepatocellular<br />
carcinoma: from bedside to proteomics. Proteomics 2001; 1:<br />
1249-1263<br />
2 Paradis V, Degos F, Dargere D, Pham N, Belghiti J, Degott C,<br />
Janeau JL, Bezeaud A, Delforge D, Cubizolles M, Laurendeau<br />
I, Bedossa P. Identification <strong>of</strong> a new marker <strong>of</strong> hepatocellular<br />
carcinoma by serum protein pr<strong>of</strong>iling <strong>of</strong> patients with chronic<br />
liver diseases. Hepatology 2005; 41: 40-47<br />
3 Li C, Tan YX, Zhou H, Ding SJ, Li SJ, Ma DJ, Man XB, Hong Y,<br />
Zhang L, Li L, Xia QC, Wu JR, Wang HY, Zeng R. Proteomic<br />
analysis <strong>of</strong> hepatitis B virus-associated hepatocellular<br />
carcinoma: Identification <strong>of</strong> potential tumor markers.<br />
Proteomics 2005; 5: 1125-1139<br />
4 Blanc JF, Lalanne C, Plomion C, Schmitter JM, Bathany K,<br />
Gion JM, Bioulac-Sage P, Balabaud C, Bonneu M, Rosenbaum<br />
J. Proteomic analysis <strong>of</strong> differentially expressed proteins in<br />
hepatocellular carcinoma developed in patients with chronic<br />
viral hepatitis C. Proteomics 2005; 5: 3778-3789<br />
5 Takashima M, Kuramitsu Y, Yokoyama Y, Iizuka N, Fujimoto<br />
M, Nishisaka T, Okita K, Oka M, Nakamura K. Overexpression<br />
<strong>of</strong> alpha enolase in hepatitis C virus-related hepatocellular<br />
carcinoma: association with tumor progression as determined<br />
by proteomic analysis. Proteomics 2005; 5: 1686-1692<br />
6 Yu LR, Zeng R, Shao XX, Wang N, Xu YH, Xia QC. Identification<br />
<strong>of</strong> differentially expressed proteins between human hepatoma<br />
and normal liver cell lines by two-dimensional electrophoresis<br />
and liquid chromatography-ion trap mass spectrometry.<br />
Electrophoresis 2000; 21: 3058-3068<br />
7 Sanchez JC, Appel RD, Golaz O, Pasquali C, Ravier F,<br />
Bairoch A, Hochstrasser DF. Inside SWISS-2DPAGE database.<br />
Electrophoresis 1995; 16: 1131-1151<br />
8 Fujii K, Kondo T, Yokoo H, Okano T, Yamada M, Yamada<br />
T, Iwatsuki K, Hirohashi S. Database <strong>of</strong> two-dimensional<br />
polyacrylamide gel electrophoresis <strong>of</strong> proteins labeled with<br />
CyDye DIGE Fluor saturation dye. Proteomics 2006; 6: 1640-1653<br />
9 Seow TK, Ong SE, Liang RC, Ren EC, Chan L, Ou K, Chung<br />
MC. Two-dimensional electrophoresis map <strong>of</strong> the human<br />
hepatocellular carcinoma cell line, HCC-M, and identification<br />
<strong>of</strong> the separated proteins by mass spectrometry. Electrophoresis<br />
2000; 21: 1787-<strong>18</strong>13<br />
10 Wu N, Zhang W, Yang Y, Liang YL, Wang LY, Jin JW, Cai XM,<br />
Zha XL. Pr<strong>of</strong>ilin 1 obtained by proteomic analysis in all-trans<br />
retinoic acid-treated hepatocarcinoma cell lines is involved in<br />
inhibition <strong>of</strong> cell proliferation and migration. Proteomics 2006; 6:<br />
6095-6106<br />
11 Li Y, Cai M, Wang Z, Liu X, Liang Z. Huaxi Yike Daxue Xuebao<br />
2002; 33: 8-11, 14<br />
12 Yuan JH, Wang XW, Luo D, Xie Y, Xie H. Anti-hepatoma<br />
activity <strong>of</strong> taxol in vitro. Acta Pharmacol Sin 2000; 21: 450-454<br />
13 Geng CX, Zeng ZC, Wang JY. Docetaxel inhibits SMMC-7721<br />
human hepatocellular carcinoma cells growth and induces<br />
apoptosis. <strong>World</strong> J Gastroenterol 2003; 9: 696-700<br />
14 Ren JG, Zheng RL, Shi YM, Gong B, Li JF. Apoptosis,<br />
redifferentiation and arresting proliferation simultaneously<br />
triggered by oxidative stress in human hepatoma cells. Cell<br />
Biol Int 1998; 22: 41-49<br />
15 Chan KT, Cheng SC, Xie H, Xie Y. A humanized monoclonal<br />
antibody constructed from intronless expression vectors<br />
targets human hepatocellular carcinoma cells. Biochem Biophys<br />
Res Commun 2001; 284: 157-167<br />
16 Garrido C, Gurbuxani S, Ravagnan L, Kroemer G. Heat shock<br />
proteins: endogenous modulators <strong>of</strong> apoptotic cell death.<br />
Biochem Biophys Res Commun 2001; 286: 433-442<br />
17 Faried A, Sohda M, Nakajima M, Miyazaki T, Kato H, Kuwano<br />
H. Expression <strong>of</strong> heat-shock protein Hsp60 correlated with the<br />
apoptotic index and patient prognosis in human oesophageal<br />
squamous cell carcinoma. Eur J Cancer 2004; 40: 2804-2811<br />
<strong>18</strong> Nylandsted J, Gyrd-Hansen M, Danielewicz A, Fehrenbacher<br />
N, Lademann U, Hoyer-Hansen M, Weber E, Multh<strong>of</strong>f G,<br />
Rohde M, Jaattela M. Heat shock protein 70 promotes cell<br />
survival by inhibiting lysosomal membrane permeabilization.<br />
J Exp Med 2004; 200: 425-435<br />
19 Zylicz M, King FW, Wawrzynow A. Hsp70 interactions with<br />
the p53 tumour suppressor protein. EMBO J 2001; 20: 4634-4638<br />
20 Cappello F, Zummo G. HSP60 expression during carcinogenesis:<br />
a molecular & quot; proteus & quot; <strong>of</strong> carcinogenesis? Cell Stress<br />
Chaperones 2005; 10: 263-264<br />
21 Jiang ZW, LeBourhis X, Hondermarck H. Progressing growth<br />
<strong>of</strong> tumor cell and synthesis <strong>of</strong> Bip/GRP78. Zhongguo Yaolixue<br />
Tongbao 2002; <strong>18</strong>: 79-83<br />
22 Diedrich G, Bangia N, Pan M, Cresswell P. A role for calnexin<br />
www.wjgnet.com
2614 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
in the assembly <strong>of</strong> the MHC class I loading complex in the<br />
endoplasmic reticulum. J Immunol 2001; 166: 1703-1709<br />
23 Ding SJ, Li Y, Shao XX, Zhou H, Zeng R, Tang ZY, Xia QC.<br />
Proteome analysis <strong>of</strong> hepatocellular carcinoma cell strains,<br />
MHCC97-H and MHCC97-L, with different metastasis<br />
potentials. Proteomics 2004; 4: 982-994<br />
24 Stierum R, Gaspari M, Dommels Y, Ouatas T, Pluk H,<br />
Jespersen S, Vogels J, Verhoeckx K, Groten J, van Ommen<br />
B. Proteome analysis reveals novel proteins associated with<br />
proliferation and differentiation <strong>of</strong> the colorectal cancer cell<br />
line Caco-2. Biochim Biophys Acta 2003; 1650: 73-91<br />
25 Zhang D, Tai LK, Wong LL, Chiu LL, Sethi SK, Koay ES.<br />
Proteomic study reveals that proteins involved in metabolic and<br />
detoxification pathways are highly expressed in HER-2/neupositive<br />
breast cancer. Mol Cell Proteomics 2005; 4: 1686-1696<br />
26 Hubbard MJ, McHugh NJ. Human ERp29: isolation, primary<br />
www.wjgnet.com<br />
structural characterisation and two-dimensional gel mapping.<br />
Electrophoresis 2000; 21: 3785-3796<br />
27 Ciocca DR, Calderwood SK. Heat shock proteins in cancer:<br />
diagnostic, prognostic, predictive, and treatment implications.<br />
Cell Stress Chaperones 2005; 10: 86-103<br />
28 He QY, Cheung YH, Leung SY, Yuen ST, Chu KM, Chiu JF.<br />
Diverse proteomic alterations in gastric adenocarcinoma.<br />
Proteomics 2004; 4: 3276-3287<br />
29 Gagne JP, Gagne P, Hunter JM, Bonicalzi ME, Lemay JF, Kelly I,<br />
Le Page C, Provencher D, Mes-Masson AM, Droit A, Bourgais<br />
D, Poirier GG. Proteome pr<strong>of</strong>iling <strong>of</strong> human epithelial ovarian<br />
cancer cell line TOV-112D. Mol Cell Biochem 2005; 275: 25-55<br />
30 Srisomsap C, Subhasitanont P, Otto A, Mueller EC, Punyarit<br />
P, Wittmann-Liebold B, Svasti J. Detection <strong>of</strong> cathepsin B upregulation<br />
in neoplastic thyroid tissues by proteomic analysis.<br />
Proteomics 2002; 2: 706-712<br />
S- Editor Liu Y L- Editor Kumar M E- Editor Zhou T
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2615-26<strong>18</strong><br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Pancreas duodenal homeobox-1 expression and significance<br />
in pancreatic cancer<br />
Tao Liu, Shan-Miao Gou, Chun-You Wang, He-Shui Wu, Jiong-Xin Xiong, Feng Zhou<br />
Tao Liu, Shan-Miao Gou, Chun-You Wang, He-Shui Wu,<br />
Jiong-Xin Xiong, Feng Zhou, Department <strong>of</strong> Pancreatic Surgery,<br />
Union Hospital, Tongji Medical College, Huazhong University <strong>of</strong><br />
Science and Technology, Wuhan 430022, Hubei Province, China<br />
Supported by the grants from the National Natural Science<br />
Foundation <strong>of</strong> China, No.3057<strong>18</strong>17, and the PhD Programs<br />
Foundation <strong>of</strong> Ministry <strong>of</strong> Education <strong>of</strong> China, No. 20050487077<br />
Correspondence to: Chun-You Wang, MD, Department <strong>of</strong><br />
Pancreatic Surgery, Union Hospital, Tongji Medical College,<br />
Huazhong University <strong>of</strong> Science and Technology, Wuhan 430022,<br />
Hubei Province, China. chunyouwang52@126.com<br />
Telephone: +86-27-85351621 Fax: +86-27-85351669<br />
Received: 2007-01-13 Accepted: 2007-01-31<br />
Abstract<br />
AIM: To study the correlations <strong>of</strong> Pancreas duodenal<br />
homeobox-1 with pancreatic cancer characteristics,<br />
including pathological grading, TNM grading, tumor<br />
metastasis and tumor cell proliferation.<br />
METHODS: Reverse transcriptase-polymerase chain<br />
reaction (RT-PCR) was used to detect PDX-1 mRNA<br />
expression in pancreatic cancer tissue and normal<br />
pancreatic tissue. The expression <strong>of</strong> PDX-1 protein was<br />
measured by Western blot and immunohistochemistry.<br />
Immunohistochemistry was also used to detect<br />
proliferative cell nuclear antigen (PCNA). Correlations <strong>of</strong><br />
PDX-1 with pancreatic cancer characteristics, including<br />
pathological grading, TNM grading, tumor metastasis<br />
and tumor cell proliferation, were analyzed by using χ 2<br />
test.<br />
RESULTS: Immunohistochemistry showed that 41.1% <strong>of</strong><br />
pancreatic cancers were positive for PDX-1 expression,<br />
but normal pancreatic tissue except islets showed no<br />
staining for PDX-1. In consistent with the result <strong>of</strong><br />
imunohistochemistry, Western blot showed that 37.5%<br />
<strong>of</strong> pancreatic cancers were positive for PDX-1. RT-PCR<br />
showed that PDX-1 expression was significantly higher in<br />
pancreatic cancer tissues than normal pancreatic tissues<br />
(2 -3.56 ± 0.35 vs 2 -8.76 ± 0.14 , P < 0.01). Lymph node metastasis<br />
(P < 0.01), TNM grading (P < 0.05), pathological grading<br />
(P < 0.05) and tumor cell proliferation (P < 0.01) were<br />
significantly correlated with PDX-1 expression levels.<br />
CONCLUSION: PDX-1 is re-expressed in pancreatic<br />
cancer, and PDX-1-positive pancreatic cancer cells show<br />
more malignant potential compared to PDX-1-negative<br />
cells. Therefore, PDX-1-positive cells may be tumor stem<br />
RAPID COMMUNICATION<br />
cells and PDX-1 may act as alternate surface marker <strong>of</strong><br />
pancreatic cancer stem cells.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Pancreatic neoplasms; Transcription factors;<br />
Tumor stem cells; Lymphatic metastasis; Biological markers<br />
Liu T, Gou SM, Wang CY, Wu HS, Xiong JX, Zhou F. Pancreas<br />
duodenal homeobox-1 expression and significance in<br />
pancreatic cancer. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>):<br />
2615-26<strong>18</strong><br />
http://www.wjgnet.com/1007-9327/13/2615.asp<br />
INTRODUCTION<br />
According to the hypothesis <strong>of</strong> cancer stem cells, only a<br />
rare, phenotypically distinct subset <strong>of</strong> cells has the capacity<br />
<strong>of</strong> forming new tumors and that this subgroup could be<br />
considered cancer stem cells, the other cells in cancers are<br />
filial generation <strong>of</strong> these cells [1] . Recently, it was reported<br />
that cancer stem cells existed in some solid malignancies,<br />
including breast, brain, prostate and lung cancers [2-6] .<br />
Although the cellular origin <strong>of</strong> cancer stem cells has not<br />
been definitively determined, evidence suggest that they<br />
may be derived from mutation <strong>of</strong> somatic stem cells<br />
caused by interaction <strong>of</strong> microenvironment, carcinogen<br />
and hereditary factors. Therefore, somatic stem cells and<br />
cancer stem cells may express the same surface markers [1] .<br />
It is reported that 90% <strong>of</strong> pancreatic cancers originate<br />
from pancreatic ducts, and PanIN (pancreatic intraepithelial<br />
neoplasia), which is a precancerous lesion, also originates<br />
from pancreatic ducts [7,8] . In addition, signal molecules that<br />
regulate proliferation and differentiation <strong>of</strong> embryonic<br />
stem cell are activated in human pancreatic cancers and<br />
mice model <strong>of</strong> pancreatic cancer. Considering that there<br />
are pancreatic stem cells located in pancreatic ducts, it is<br />
possible that pancreatic cancer originates from these stem<br />
cells [9] .<br />
Pancreas duodenal homeobox-1 is a key transcription<br />
factor in embryonic pancreas development, it is critical<br />
for ensuring proper embryonic development <strong>of</strong> the<br />
endocrine pancreas and normal islet function and act<br />
as a marker <strong>of</strong> pancreatic stem cells [10] . PDX-1 is found<br />
in the mouse primitive gut as early as the stage <strong>of</strong> 8.5<br />
d, it directs the pancreatic stem cells differentiation by<br />
promoting expression <strong>of</strong> molecules which are associated<br />
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26<strong>18</strong> ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
in rat pancreatectomy model and PDX-1 was re-activated<br />
in the ductal cells, thereby suggesting that re-activation <strong>of</strong><br />
PDX-1 is a marker <strong>of</strong> pancreatic stem cells.<br />
There is overwhelming evidence that cancer stem<br />
cells, which are considered to originate from somatic stem<br />
cells, should be responsible for tumors malignancy [17] .<br />
Miyamoto et al [9] found that signal molecules that regulate<br />
proliferation and differentiation <strong>of</strong> embryonic stem cell<br />
were activated in human pancreatic cancers. Thus, we<br />
deduced that PDX-1 may be re-activated in the process <strong>of</strong><br />
transformation from pancreatic stem cells to pancreatic<br />
cancer stem cells.<br />
To investigate whether PDX-1 was re-expressed<br />
in pancreatic cancer and its role in pancreatic cancer<br />
development, we detected PDX-1 protein and mRNA<br />
expression in 56 pancreatic cancer tissues. To validate<br />
the used methods, we also analyzed normal human<br />
pancreatic tissues. Results <strong>of</strong> immunohistochemistry<br />
indicated that PDX-1 was only weekly expressed in beta<br />
cells <strong>of</strong> the pancreatic islet in normal pancreatic tissues,<br />
which is in agreement with previous studies in mice and<br />
human pancreas [11,12] , but PDX-1 was re-activated in<br />
pancreatic cancers. About 41.1% samples showed positive<br />
immunostaining for PDX-1 in the cytoplasm and nuclei<br />
<strong>of</strong> cells, especially in the cells located at the leading edge<br />
<strong>of</strong> infiltration, thereby implying that PDX-1 plays a role in<br />
pancreatic cancer infiltration. Results <strong>of</strong> Western blot were<br />
in consonance with that <strong>of</strong> immunohistochemistry. In<br />
addition, we analyzed the correlation <strong>of</strong> PDX-1 expression<br />
with tumor characteristics. We found that lymph node<br />
metastasis, TNM grading and pathological grading were all<br />
significantly correlated with PDX-1 expression.<br />
To study the correlation <strong>of</strong> PDX-1 expression with<br />
cell proliferation, we detected the expression <strong>of</strong> PCNA in<br />
pancreatic cancer by immunohistochemistry. The positive<br />
rate <strong>of</strong> PCNA in PDX-1-positive samples was as high as<br />
78.2%, whereas that in PDX-1-negative samples was only<br />
36.4%, suggesting that PDX-1-positive cells had higher<br />
potential <strong>of</strong> proliferation. Many studies have demonstrated<br />
high frequency <strong>of</strong> mutations <strong>of</strong> oncogene such as K-ras<br />
and tumor suppressor genes such as p16, p53 in pancreatic<br />
cancer tissues and cell lines [8,<strong>18</strong>,19] . Based on our study, we<br />
deduced that the alteration <strong>of</strong> PDX-1 expression might<br />
represent one <strong>of</strong> those genetic changes.<br />
In summary, PDX-1 is re-expressed in pancreatic<br />
cancers, and its expression level has a significant correlation<br />
with pathological grading, TNM grading, tumor metastasis<br />
and tumor cell proliferation. Since PDX-1 is considered a<br />
marker <strong>of</strong> pancreatic stem cells, we tentatively put forward<br />
that cells that express PDX-1 in pancreatic cancers may be<br />
cancer stem cells. How does the PDX-1 molecule affect<br />
the malignancy <strong>of</strong> a particular cell is awaited to be studied<br />
in our future work.<br />
ACKNOWLEDGMENTS<br />
The authors are grateful to the technical assistance from<br />
Yuan Tian and Jin-Hui Zhang, the Research Laboratory <strong>of</strong><br />
www.wjgnet.com<br />
General Surgery, Union Hospital, Wuhan.<br />
REFERENCES<br />
1 Pardal R, Clarke MF, Morrison SJ. Applying the principles <strong>of</strong><br />
stem-cell biology to cancer. Nat Rev Cancer 2003; 3: 895-902<br />
2 Bonnet D, Dick JE. Human acute myeloid leukemia is<br />
organized as a hierarchy that originates from a primitive<br />
hematopoietic cell. Nat Med 1997; 3: 730-737<br />
3 Al-Hajj M, Wicha MS, Benito-Hernandez A, Morrison SJ,<br />
Clarke MF. Prospective identification <strong>of</strong> tumorigenic breast<br />
cancer cells. Proc Natl Acad Sci USA 2003; 100: 3983-3988<br />
4 Singh SK, Clarke ID, Terasaki M, Bonn VE, Hawkins C, Squire<br />
J, Dirks PB. Identification <strong>of</strong> a cancer stem cell in human brain<br />
tumors. Cancer Res 2003; 63: 5821-5828<br />
5 Collins AT, Berry PA, Hyde C, Stower MJ, Maitland NJ.<br />
Prospective identification <strong>of</strong> tumorigenic prostate cancer stem<br />
cells. Cancer Res 2005; 65: 10946-10951<br />
6 Kim CF, Jackson EL, Woolfenden AE, Lawrence S, Babar I,<br />
Vogel S, Crowley D, Bronson RT, Jacks T. Identification <strong>of</strong><br />
bronchioalveolar stem cells in normal lung and lung cancer.<br />
Cell 2005; 121: 823-835<br />
7 Bonner-Weir S, Taneja M, Weir GC, Tatarkiewicz K, Song KH,<br />
Sharma A, O’Neil JJ. In vitro cultivation <strong>of</strong> human islets from<br />
expanded ductal tissue. Proc Natl Acad Sci USA 2000; 97: 7999-8004<br />
8 Aguirre AJ, Bardeesy N, Sinha M, Lopez L, Tuveson DA,<br />
Horner J, Redston MS, DePinho RA. Activated Kras and<br />
Ink4a/Arf deficiency cooperate to produce metastatic<br />
pancreatic ductal adenocarcinoma. Genes Dev 2003; 17:<br />
3112-3126<br />
9 Miyamoto Y, Maitra A, Ghosh B, Zechner U, Argani P,<br />
Iacobuzio-Donahue CA, Sriuranpong V, Iso T, Meszoely IM,<br />
Wolfe MS, Hruban RH, Ball DW, Schmid RM, Leach SD.<br />
Notch mediates TGF alpha-induced changes in epithelial<br />
differentiation during pancreatic tumorigenesis. Cancer Cell<br />
2003; 3: 565-576<br />
10 Edlund H. Pancreatic organogenesis--developmental<br />
mechanisms and implications for therapy. Nat Rev Genet 2002;<br />
3: 524-532<br />
11 Jonsson J, Carlsson L, Edlund T, Edlund H. Insulin-promoterfactor<br />
1 is required for pancreas development in mice. Nature<br />
1994; 371: 606-609<br />
12 Gerrish K, Gannon M, Shih D, Henderson E, St<strong>of</strong>fel M, Wright<br />
CV, Stein R. Pancreatic beta cell-specific transcription <strong>of</strong> the pdx-1<br />
gene. The role <strong>of</strong> conserved upstream control regions and their<br />
hepatic nuclear factor 3beta sites. J Biol Chem 2000; 275: 3485-3492<br />
13 Risbud MV, Bhonde RR. Models <strong>of</strong> pancreatic regeneration in<br />
diabetes. Diabetes Res Clin Pract 2002; 58: 155-165<br />
14 Sharma A, Zangen DH, Reitz P, Taneja M, Lissauer ME, Miller<br />
CP, Weir GC, Habener JF, Bonner-Weir S. The homeodomain<br />
protein IDX-1 increases after an early burst <strong>of</strong> proliferation<br />
during pancreatic regeneration. Diabetes 1999; 48: 507-513<br />
15 Hosotani R, Ida J, Kogire M, Fujimoto K, Doi R, Imamura M.<br />
Expression <strong>of</strong> pancreatic duodenal hoemobox-1 in pancreatic islet<br />
neogenesis after surgical wrapping in rats. Surgery 2004; 135: 297-306<br />
16 Marshak S, Benshushan E, Shoshkes M, Havin L, Cerasi E,<br />
Melloul D. Functional conservation <strong>of</strong> regulatory elements in<br />
the pdx-1 gene: PDX-1 and hepatocyte nuclear factor 3beta<br />
transcription factors mediate beta-cell-specific expression. Mol<br />
Cell Biol 2000; 20: 7583-7590<br />
17 Reya T, Morrison SJ, Clarke MF, Weissman IL. Stem cells,<br />
cancer, and cancer stem cells. Nature 2001; 414: 105-111<br />
<strong>18</strong> Jeong J, Park YN, Park JS, Yoon DS, Chi HS, Kim BR. Clinical<br />
significance <strong>of</strong> p16 protein expression loss and aberrant p53 protein<br />
expression in pancreatic cancer. Yonsei Med J 2005; 46: 519-525<br />
19 Khorana AA, Hu YC, Ryan CK, Komorowski RA, Hostetter<br />
G, Ahrendt SA. Vascular endothelial growth factor and DPC4<br />
predict adjuvant therapy outcomes in resected pancreatic<br />
cancer. J Gastrointest Surg 2005; 9: 903-911<br />
S- Editor Liu Y L- Editor Kumar M E- Editor Wang HF
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2619-2621<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Surgical management <strong>of</strong> 143 patients with adult primary<br />
retroperitoneal tumor<br />
Yuan-Hong Xu, Ke-Jian Guo, Ren-Xuan Guo, Chun-Lin Ge, Yu-Lin Tian, San-Guang He<br />
Yuan-Hong Xu, Ke-Jian Guo, Ren-Xuan Guo, Chun-Lin Ge,<br />
Yu-Lin Tian, San-Guang He, Department <strong>of</strong> General Surgery,<br />
The First Affiliated Hospital <strong>of</strong> China Medical University,<br />
Shenyang 110001, Liaoning Province, China<br />
Correspondence to: Dr. Yuan-Hong Xu, Department <strong>of</strong><br />
General Surgery, The First Affiliated Hospital <strong>of</strong> China Medical<br />
University, 155 North Nanjing Street, Heping District, Shenyang<br />
110001, Liaoning Province, China. xu_yuanhong@yahoo.com<br />
Telephone: +86-24-83283330 Fax: +86-24-251<strong>18</strong>399<br />
Received: 2007-01-08 Accepted: 2007-01-31<br />
Abstract<br />
AIM: To anal��e anal��e the surgical �anage�ent �anage�ent o�� o�� adult<br />
pri�ar� retroperitoneal tu�ors (APRT) and the ��actors<br />
influencing the outcome after operation.<br />
METHODS: Data o�� 143 cases o�� APRT ��ro� 1990 to<br />
2003 in the First A����iliated Hospital o�� China Medical<br />
Universit� were evaluated retrospectivel�.<br />
RESULTS: A total o�� 143 cases o�� APRT were treated<br />
surgicall�. A�ong the�, 122 (85.3%) underwent<br />
co�plete resection, 16 (11.2%) inco�plete resection,<br />
and 3 (3%) surgical biopsies. Twent�-nine (20.2%)<br />
underwent tu�or resection plus �ultiple organ<br />
resections. Ninet�-��ive �alignant cases were ��ollowed<br />
up ��or 1 �o to 5 �ears. The 1-�ear, 3-�ear, and 5-�ear<br />
survival rates o�� the patients subject to co�plete<br />
resection was 94.9%, 76.6% and 34.3% and that o��<br />
patients with inco�plete resection was 80.4%, 6.7%,<br />
and 0%, respectivel� (P < 0.001). The Cox �ulti-various<br />
regression anal�sis showed the co�pleteness o�� tu�or,<br />
sex and histological t�pe were associated closel� with<br />
local recurrence.<br />
CONCLUSION: Su����icient preoperative preparation<br />
and co�plete tu�or resection pla� i�portant roles in<br />
reducing recurrence and i�proving survival.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Retroperitoneal neoplas�s; Surgical procedure;<br />
Operative; Recurrence<br />
Xu YH, Guo KJ, Guo RX, Ge CL, Tian YL, He SG. Surgical<br />
�anage�ent o�� 143 patients w i t h adult pri�ar�<br />
retroperitoneal tu�or. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>):<br />
2619-2621<br />
http://www.wjgnet.co�/1007-9327/13/2619.asp<br />
INTRODUCTION<br />
RAPID COMMUNICATION<br />
Adult primary retroperitoneal tumor (APRT) is a rare<br />
but diverse group <strong>of</strong> neoplasms that arise within the<br />
retroperitoneal space. It comprises about 0.2%-0.5% <strong>of</strong><br />
all malignant tumors. Surgical resection is difficult because<br />
<strong>of</strong> the proximity <strong>of</strong> vital structures <strong>of</strong> the retroperitoneal<br />
and adjacent vascularities. These affect local recurrence,<br />
postoperative outcomes and long-term survival rates [1,2] .<br />
A retrospective review <strong>of</strong> 143 cases <strong>of</strong> APRT in the<br />
First Affiliated Hospital <strong>of</strong> China Medical University was<br />
performed to analyze the factors influencing postoperative<br />
outcomes and optimize treatment strategies.<br />
MATERIALS AND METHODS<br />
General materials<br />
From January 1990 to April 2003, 143 patients (89 males<br />
and 54 females) with APRT were treated in the First<br />
Affiliated Hospital <strong>of</strong> CMU. The mean age was 52 years<br />
(19-81 years). The clinical course range from 1 mo to 12<br />
years, averaging 12 mo. The mean course <strong>of</strong> benign cases<br />
was 20 mo while malignant ones was 9 mo. The tumors<br />
were 6-32 cm in diameter with a mean <strong>of</strong> 13 cm. Mean<br />
diameter <strong>of</strong> benign tumors was 7 cm while it was 15<br />
cm for malignant ones. Four patients had no symptoms<br />
when taking physical examinations, while 139 had<br />
clinical manifestations (Table 1). All patients underwent<br />
ultrasonography, computerized tomography (CT) and/<br />
or magnetic resonance imaging (MRI). A total <strong>of</strong> 122<br />
(85.3%) patients underwent DSA. All patients with APRT<br />
received surgical therapy and pathological evaluation.<br />
Surgical therapy<br />
Of the 143 patients, 122 underwent complete resection<br />
(85.5%), 43 (95.6%) <strong>of</strong> 45 benign cases and 79 (80.6%)<br />
<strong>of</strong> 98 malignant cases underwent complete resection.<br />
Sixteen (11.3%) <strong>of</strong> 143 underwent incomplete resection.<br />
Three (3%) <strong>of</strong> 143 had surgical biopsies. Twenty-nine<br />
(20.2%) patients underwent tumor resection plus multiple<br />
organ resections (Table 2). During operations, the mean<br />
amount <strong>of</strong> blood transfusion was 1150 mL, 800 mL for<br />
benign cases and 1356 mL for malignant ones. All had<br />
postoperative pathological diagnosis.<br />
Statistical analysis<br />
The comparison <strong>of</strong> survival rate between complete<br />
and incomplete resection groups was performed by χ 2<br />
test. COX regression analysis was performed using an<br />
independent variable (male, malignant tumor, completeness<br />
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2620 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol Ma� 14, 2007 Volu�e 13 Nu�ber <strong>18</strong><br />
Table 1 Clinical manifestation <strong>of</strong> 139 patients<br />
Clinical manifestations n (%)<br />
Abdominal mass 84 (60.4)<br />
Abdominal pain 72 (51.8)<br />
Abdominal distension 26 (<strong>18</strong>.7)<br />
Lumbar region pain 23 (16.5)<br />
Fever 11 (8.0)<br />
Constipation 11 (8.0)<br />
Lower extremity edema 9 (6.5)<br />
Weight loss 7 (5.0)<br />
Lower limb pain 7 (5.0)<br />
Dysuria 6 (4.3)<br />
Lower limb numbness 5 (3.6)<br />
Loss <strong>of</strong> appetite 5 (3.6)<br />
Table 2 Patients underwent multiple organs resection (n = 29)<br />
Surgery n<br />
Nephrectomy 16<br />
Partial colorectomy 15<br />
Splenectomy 11<br />
Distal Panctratectomy 8<br />
Artificial blood vessel transplantation 7<br />
Partial small intestine resection 6<br />
Partial ureterectomy 6<br />
Partial duodenectomy 4<br />
Partial gastrectomy 4<br />
Uterectomy 3<br />
<strong>of</strong> tumor resection, histological types) and dependent<br />
variable (recurrence, survival rate). Statistical s<strong>of</strong>tware<br />
SPSS 13.0 version was used.<br />
RESULTS<br />
Pathological results<br />
The tumor histological types <strong>of</strong> 143 patients are summarized<br />
in Table 3.<br />
Follow-up<br />
Ninety-five malignant patients were followed up, including<br />
79 complete resection cases and 16 incomplete resection<br />
cases. The cut-<strong>of</strong>f time was 5 years. Four patients were<br />
lost to follow-up. By the method <strong>of</strong> Kaplan-Meier survival<br />
analysis for statistical significance, the means and medians<br />
for survival time in the complete resection group was 49<br />
mo, and that in the incomplete resection group was 19 mo.<br />
The 1-year, 3-year and 5-year survival rates was 94.9%,<br />
76.6% and 34.3% in the complete resection group and<br />
80.4%, 6.7%, and 0% in the incomplete resection group<br />
(Figure 1, P < 0.001). Local recurrence occurred in 28<br />
malignant patients. Among them, 26 were subjected to reoperation<br />
or multiple surgical resection. COX regression<br />
analysis showed that completeness <strong>of</strong> tumor resection, sex<br />
and histological types were associated closely with local<br />
recurrence. Liposarcoma, leiomyosarcoma and malignant<br />
hemangioendothelioma were the 3 main histological types<br />
that tended to recur (Table 4).<br />
www.wjgnet.com<br />
Table 3 Histological types <strong>of</strong> 143 cases <strong>of</strong> APRT<br />
Tissue source Benign n Malignant n<br />
Mesenchymal Lipoma 5 Liposarcoma 21<br />
tissue Leiomyoma 4 Leiomyosarcoma 16<br />
Lymphangioma 3 Rhabdomyosarcoma 11<br />
Fibroma 4 Malignant fibrous histiocytoma 8<br />
Hemangioma 5 Malignant mesenchymoma 6<br />
Mesenchymoma 4 Malignant lymphoma 5<br />
Malignant hemangioendothelioma 6<br />
Scirrhous fibroma 2<br />
Neurogenous Neur<strong>of</strong>ibroma 5 Malignant neur<strong>of</strong>ibroma 9<br />
tissue Paraganglioma 2 Malignant Paraganglioma 3<br />
Schwannnoma 4 Malignant schwannoma 4<br />
Geitoembryo<br />
tissue<br />
Teratoma 5 Malignant teratoma 6<br />
Overall survival (%)<br />
Unclassified<br />
tumor<br />
DISCUSSION<br />
Retroperitoneal<br />
cyst<br />
4 Undifferentiated sarcoma 1<br />
Total 45 98<br />
1.0<br />
0.8<br />
0.6<br />
0.4<br />
0.2<br />
0.0<br />
0.00 10.00 20.00 30.00 40.00 50.00 60.00<br />
Ti�e a��ter operation (�o)<br />
Co�plete<br />
resection<br />
Inco�plete<br />
resection<br />
Co�plete<br />
resectioncensored<br />
Inco�plete<br />
resectioncensored<br />
Figure 1 Overall survival <strong>of</strong> malignant patients who had complete resection and<br />
those who had incomplete resection.<br />
Surgical strategy remains the mainstay for the treatment<br />
<strong>of</strong> ARPT, because <strong>of</strong> the lack <strong>of</strong> effective adjuvant<br />
therapies [3] . The source <strong>of</strong> APRT is different and usually<br />
deep. The symptoms are not typical. It always has a long<br />
time <strong>of</strong> growth before discovery. All <strong>of</strong> these factors<br />
contribute to great difficulties for treatment.<br />
Sufficient preoperative preparation is the key to<br />
successful operations. Preoperative ultrasonography, CT,<br />
MRI and DSA can clearly demonstrate the localization <strong>of</strong><br />
tumors and the close proximity <strong>of</strong> organs and adjacent<br />
vascularities. These would be helpful in making precise<br />
surgical plans. Meanwhile, renal function should be<br />
examined and the preparation <strong>of</strong> intestinal canal should<br />
be done in case <strong>of</strong> combined resection. Sufficient blood<br />
should be prepared according to the size and localization<br />
<strong>of</strong> the tumor, and also prepared for vessel resection and<br />
reconstruction [4] . In our report, all patients underwent<br />
ultrasonography, CT and/or MRI. One-hundred and<br />
twenty-two (85.3%) underwent DSA, which can clearly<br />
show the location, size, appearance <strong>of</strong> the tumor and<br />
invasion tissues and organs, especially its association with<br />
main blood vessel [4] . All these examinations mentioned
Xu YH et al . Adult pri�ar� retroperitoneal etroperitoneal tu�or tu�or tu�or tu�or u�or 2621<br />
Table 4 Factors affecting postoperative local recurrence (COX<br />
regression analysis results)<br />
B SE P RR RR95%CI<br />
Male 0.346 0.176 0.049 1.413 1.001-1.996<br />
Malignant tumor 2.865 0.841 0.000 17.549 3.376-91.228<br />
Completeness <strong>of</strong> tumor<br />
resection<br />
-0.493 0.<strong>18</strong>2 0.007 0.611 0.427-0.873<br />
Leiomyosarcoma 0.849 0.333 0.011 2.338 1.217-4.493<br />
Liposarcoma 0.806 0.287 0.005 2.239 1.276-3.929<br />
Malignant<br />
hemangioendothelioma<br />
0.817 0.446 0.067 2.264 0.944-5.426<br />
above provided more accurate information for further<br />
surgical procedures. In our report, 29 patients (20.2%)<br />
underwent multiple organ resections and 7 underwent<br />
vessel reconstruction. One-hundred and twenty-two<br />
patients (85.3%) were subjected to complete tumor<br />
resection. Previous reports showed the most important<br />
reason for incomplete resection was vascular invasion. In<br />
our experience, if the inferior vena cava was obstructed or<br />
had collateral circulation, reconstruction was not necessary<br />
after resection, otherwise the reconstruction needed to be<br />
performed. As a result, sufficient preoperative preparation,<br />
positive multiple organ resections, vessel reconstruction all<br />
contributed to a higher complete resection rate.<br />
The retroperitoneal space is deep with sufficient blood<br />
circulation, and the tumors are complicated. Thus, the<br />
operative field should be completely exposed, easy to<br />
anatomize and easy to perform hemostasis. Large surgical<br />
incision, sufficient exposure and favorable surgical visual<br />
field are important for successful operation, reduction <strong>of</strong><br />
complications and higher safety. The pseudomembrane <strong>of</strong><br />
the tumor should be identified before the anatomy <strong>of</strong> the<br />
tumor. Separating along the pseudomembrane provides<br />
less bleeding and prevents accidental injury. Operation <strong>of</strong><br />
the tumor should be performed gradually, which means<br />
easier parts should be dealt with first. Surgeons should<br />
control proximal blood flow before separating the tumor,<br />
and they should have the techniques to handle injured<br />
vessels and to reconstruct after vascular resection.<br />
Complete resection <strong>of</strong> retroperitoneal tumors refers<br />
to the complete resection <strong>of</strong> a tumor which can be seen<br />
by the naked eye, including the pseudomembrane <strong>of</strong> the<br />
tumor. This does not include the incisal margin or tumor<br />
residue <strong>of</strong> the tumor bed under microscopy [5,6] . This is the<br />
best condition for surgical therapy <strong>of</strong> a retroperitoneal<br />
tumor. If necessary, resection <strong>of</strong> the whole mass <strong>of</strong> the<br />
retroperitoneal tumor can be performed. This includes the<br />
resection <strong>of</strong> the tumor and the organ tissue that can not<br />
be separated because <strong>of</strong> tumor invasion. This can assure<br />
complete resection <strong>of</strong> the tumor with a sufficient amount<br />
<strong>of</strong> normal tissue.<br />
Incomplete resection <strong>of</strong> PRT is proper for those<br />
patients who have widespread metastasis in the abdominal<br />
cavity or whose tumors can not be completely excised<br />
even with great efforts because <strong>of</strong> invasion to vessels and/<br />
or multiple organs. The purpose <strong>of</strong> this operation is to<br />
reduce the tumor burden and relieve pressing symptoms.<br />
Complete resection was not available in some cases in this<br />
group. Five cases were because <strong>of</strong> vascular invasion, 6<br />
cases due to metastasis in the abdominal cavity and 5 cases<br />
because <strong>of</strong> adjacent organ invasion.<br />
It was reported that local recurrence varies from 40% to<br />
82% and the median recurrence time ranges from 15 to 44<br />
mo [7,8] . The recurrent rate <strong>of</strong> tumors is high for malignant<br />
tumors. Until now, operations are still the best treatment.<br />
Re-operations are needed when constitution is good and<br />
resection is effective. Among the 95 cases followed up, 28<br />
cases (29.47%) had local recurrence, 26 cases <strong>of</strong> which<br />
underwent re-operation. In these cases, the results showed<br />
longer survival time and improved quality <strong>of</strong> life. We<br />
suggest that post-operative ARPT patients should have a<br />
physical examination every 3 mo. CT and MRI should be<br />
done as soon as abdominal mass, abdominal pain and other<br />
symptoms are found. To those without symptoms, followup<br />
by CT scans or MRI at 6-mo intervals can be valuable<br />
for early diagnosis to improve survival.<br />
Postoperative follow-up ranged from 1 mo to 5<br />
years. The 1-year, 3-year and 5-year survival rates were<br />
obviously higher than those in incomplete resection<br />
patients. COX multi-various regression analysis revealed<br />
that completeness <strong>of</strong> tumor resection, sex and histologic<br />
types were associated with local recurrence. This is similar<br />
with other reports [9] . In summary, the steps to improve<br />
therapeutic effectiveness include: (1) Complete resection;<br />
(2) early finding, early diagnosis, and early surgical<br />
intervention.<br />
REFERENCES<br />
1 Chiappa A, Zbar AP, Bertani E, Biffi R, Luca F, Crotti C,<br />
Testori A, Lazzaro G, De Pas T, Ugo P, Andreoni B. Primary<br />
and recurrent retroperitoneal s<strong>of</strong>t tissue sarcoma: prognostic<br />
factors affecting survival. J Surg Oncol 2006; 93: 456-463<br />
2 Wendtner CM, Abdel-Rahman S, Krych M, Baumert J, Lindner<br />
LH, Baur A, Hiddemann W, Issels RD. Response to neoadjuvant<br />
chemotherapy combined with regional hyperthermia predicts<br />
long-term survival for adult patients with retroperitoneal and<br />
visceral high-risk s<strong>of</strong>t tissue sarcomas. J Clin Oncol 2002; 20:<br />
3156-3164<br />
3 Scibe R, Massa M, Verdolini R, Marmorale C, Landi E.<br />
Retroperitoneal tumors. Ann Ital Chir 1999; 70: 731-736;<br />
discussion 736-738<br />
4 Schwarzbach MH, Hormann Y, Hinz U, Leowardi C, Bockler<br />
D, Mechtersheimer G, Friess H, Buchler MW, Allenberg JR.<br />
Clinical results <strong>of</strong> surgery for retroperitoneal sarcoma with<br />
major blood vessel involvement. J Vasc Surg 2006; 44: 46-55<br />
5 Stojadinovic A, Yeh A, Brennan MF. Completely resected<br />
recurrent s<strong>of</strong>t tissue sarcoma: primary anatomic site governs<br />
outcomes. J Am Coll Surg 2002; 194: 436-447<br />
6 Neuhaus SJ, Barry P, Clark MA, Hayes AJ, Fisher C,<br />
Thomas JM. Surgical management <strong>of</strong> primary and recurrent<br />
retroperitoneal liposarcoma. Br J Surg 2005; 92: 246-252<br />
7 Heslin MJ, Lewis JJ, Nadler E, Newman E, Woodruff<br />
JM, Casper ES, Leung D, Brennan MF. Prognostic factors<br />
associated with long-term survival for retroperitoneal sarcoma:<br />
implications for management. J Clin Oncol 1997; 15: 2832-2839<br />
8 Bautista N, Su W, O'Connell TX. Retroperitoneal s<strong>of</strong>t-tissue<br />
sarcomas: prognosis and treatment <strong>of</strong> primary and recurrent<br />
disease. Am Surg 2000; 66: 832-836<br />
9 O u y a n g X H , K o n g G C . C l i n i c a l s t u d y o f p r i m a r y<br />
retroperitoneal tumor in 66 cases. Zhongguo Putong Waike<br />
Zazhi, 1996, 5: 327-328<br />
S- Editor Wang J L- Editor Ma JY E- Editor Wang HF<br />
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www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
RAPID COMMUNICATION<br />
Expression level <strong>of</strong> beta-catenin is associated with prognosis<br />
<strong>of</strong> esophageal carcinoma<br />
Lv Ji, Xiu-Feng Cao, He-Ming Wang, Yi-Sheng Li, Bin Zhu, Jian Xiao, Dan Wang<br />
Lv Ji, Xiu-Feng Cao, He-Ming Wang, Yi-Sheng Li, Bin Zhu,<br />
Jian Xiao, Dan Wang, Affillted Nanjing First Hospital, Nanjing<br />
Medical University, Nanjing 210006, Jiangsu Province, China<br />
Correspondence to: Xiu-Feng Cao, Affillted Nanjing First<br />
Hospital Oncology Center, Nanjing Medical University, Changle<br />
Road, Nanjing 230032, Jiangsu Province,<br />
China. cxf551101@sina.com<br />
Telephone: +86-25-52271474 Fax: +86-25-52269924<br />
Received: 2007-01-16 Accepted: 2007-03-23<br />
Abstract<br />
AIM: To examine the association <strong>of</strong> beta-catenin<br />
with the clinicopathologic features and prognosis <strong>of</strong><br />
esophageal squamous cell carcinoma (ESCC).<br />
METHODS: Beta-catenin mRNA expression level in 40<br />
ESCC patients (28 males and 12 females, age range<br />
38-82 years, median 60 years) was analyzed by realtime<br />
PCR. Beta-catenin mRNA expression levels in tumor<br />
cells were categorized as weaker (level 1) or equal to<br />
or stronger (level 2) than those in endothelial cells. We<br />
examined the correlation between the beta-catenin<br />
expression and the clinicopathological factors and<br />
prognosis <strong>of</strong> ESCC patients.<br />
RESULTS: Level 2 beta-catenin expression was found in<br />
29 patients. ESCC with level 2 expression had a higher<br />
rate <strong>of</strong> lymphnode metastasis (0.0776 ± 0.0369 vs<br />
0.3413 ± 0.<strong>18</strong>03, P < 0.001) and deeper tumor invasion<br />
(0.0751 ± 0.0356 vs 0.3667 ± 0.1928, P < 0.001), and<br />
a poorer survival rate (P = 0.0024) than ESCC with level<br />
1 expression.<br />
CONCLUSION: Beta-catenin expression in ESCC is <strong>of</strong><br />
great importance.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Beta-catenin; mRNA expression level;<br />
Esophageal carcinoma; Prognosis<br />
Ji L, Cao XF, Wang HM, Li YS, Zhu B, Xiao J, Wang D.<br />
Expression level <strong>of</strong> beta-catenin is associated with prognosis<br />
<strong>of</strong> esophageal carcinoma. <strong>World</strong> J Gastroenterol 2007;<br />
13(<strong>18</strong>): 2622-2625<br />
http://www.wjgnet.com/1007-9327/13/2622.asp<br />
www.wjgnet.com<br />
INTRODUCTION<br />
Esophageal squamous cell carcinoma (ESCC) shows a<br />
poor prognosis because <strong>of</strong> the occurrence <strong>of</strong> systemic<br />
metastasis, mainly via lymphatic vessels [1–6] . Detection <strong>of</strong><br />
ESCC at its early stage is possible by X-ray and endoscopic<br />
examinations [7,8] , but there might be occult micrometastases<br />
at the time <strong>of</strong> surgery even in such cases [9,10] . In this<br />
respect, an assessment <strong>of</strong> metastatic potential is important<br />
to establish appropriate therapeutic modalities for ESCC.<br />
Previous studies have shown the prognostic significance<br />
<strong>of</strong> several clinicopathologic factors for ESCC, such as<br />
tumor size, age at diagnosis, and primary site [11,12] . Among<br />
them, depth <strong>of</strong> cancer invasion in the esophageal wall<br />
and lymph node metastasis are the main factors for ESCC<br />
recurrence [5,6,11] , and these two factors as well as distant<br />
metastasis have been included in the pathological tumornode-metastasis<br />
(pTNM) staging for ESCC [12] . However,<br />
the prognosis <strong>of</strong> ESCC, even in cases <strong>of</strong> early-stage<br />
disease (pT1), is heterogeneous, and a strategy to establish<br />
appropriate therapeutic modalities for each patient has yet<br />
to be formulated.<br />
Several biological indices for predicting the prognosis<br />
<strong>of</strong> ESCC, a number <strong>of</strong> indices, such as aberrant expression<br />
or mutation <strong>of</strong> the tumor suppressor p53, adhesion<br />
molecule Ecadherin, and cell-cycle-related molecules such<br />
as p27, have been proposed [3,13,11] . However, the utility <strong>of</strong><br />
these factors for predicting the prognosis <strong>of</strong> ESCC is<br />
controversial [15] .<br />
Recently, beta catenin and elements <strong>of</strong> the Wnt<br />
signaling pathway have been found to play an important<br />
role in the pathogenesis <strong>of</strong> human cancers including<br />
ESCC. In the present study, we analyzed beta-catenin<br />
mRNA expression level in 40 patients with ESCC and<br />
evaluated its correlation with the clinicopathologic features<br />
and survival <strong>of</strong> these patients.<br />
MATERIALS AND METHODS<br />
Patients<br />
In the present study, 40 patients underwent surgery for<br />
ESCC at the Nanjing First Hospital Affiliated to Nanjing<br />
Medical University from July 1999 to February 2000<br />
were selected. There were 28 males and 12 females (age<br />
range 38-82 years, median 60 years). An endoscopic<br />
examination <strong>of</strong> esophageal lesions was performed, and<br />
a histologic diagnosis <strong>of</strong> ESCC was made based on<br />
biopsy specimens obtained before surgery. Preoperative
Ji L et al . Beta-catenin associated with prognosis <strong>of</strong> esophageal carcinoma 2625<br />
be a good guide for choosing the modalities <strong>of</strong> adjuvant<br />
therapy. In early ESCC patients with beta-catenin level 1<br />
expression, a favorable outcome could be expected. Since<br />
lymph node metastasis was observed in only 20% <strong>of</strong><br />
these patients, reduction surgeries might be considered,<br />
particularly for those in a poor general condition or with<br />
small tumors. In contrast, patients with level 2 ESCC and<br />
advanced stage disease might have a dismal prognosis, and<br />
the introduction <strong>of</strong> intensive adjuvant therapies for these<br />
patients might be justified.<br />
In conclusion, beta-catenin mRNA expression level is<br />
a new prognostic marker for ESCC. The stratification <strong>of</strong><br />
ESCC patients based on the disease stage and beta-catenin<br />
expression level is valuable for predicting tumor recurrence<br />
and prognosis. This system might provide a novel way to<br />
explore effective treatment modalities for ESCC.<br />
REFERENCES<br />
1 Dawsey SM, Wang GQ, Weinstein WM, Lewin KJ, Liu FS,<br />
Wiggett S, Nieberg RK, Li JY, Taylor PR. Squamous dysplasia<br />
and early esophageal cancer in the Linxian region <strong>of</strong> China:<br />
distinctive endoscopic lesions. <strong>Gastroenterology</strong> 1993; 105:<br />
1333-1340<br />
2 Faivre J, Forman D, Esteve J, Gatta G. Survival <strong>of</strong> patients with<br />
oesophageal and gastric cancers in Europe. Eur J Cancer 1998;<br />
34: 2167-2175<br />
3 Eloubeidi MA, Desmond R, Arguedas MR, Reed CE, Wilcox<br />
CM. Prognostic factors for the survival <strong>of</strong> patients with<br />
esophageal carcinoma in the US.: the importance <strong>of</strong> tumor<br />
length and lymph node status. Cancer 2002; 95: 1434-1443<br />
4 Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer<br />
statistics, 2001. CA Cancer J Clin 2001; 51: 15-36<br />
5 Ueyama T, Kawamoto K, Yamada Y, Masuda K. Early<br />
esophageal carcinoma. Evaluation <strong>of</strong> the depth <strong>of</strong> invasion<br />
based on double-contrast esophagography. Acta Radiol 1998;<br />
39: 133-137<br />
6 Lambert R. Diagnosis <strong>of</strong> esophagogastric tumors. Endoscopy<br />
2002; 34: 129-138<br />
7 Nozoe T, Saeki H, Ohga T, Sugimachi K. Clinicopathological<br />
features <strong>of</strong> early esophageal squamous cell carcinoma with<br />
subsequent recurrence. Dis Esophagus 2002; 15: 145-148<br />
8 Lam KY, Tsao SW, Zhang D, Law S, He D, Ma L, Wong J.<br />
Prevalence and predictive value <strong>of</strong> p53 mutation in patients<br />
with oesophageal squamous cell carcinomas: a prospective<br />
clinico-pathological study and survival analysis <strong>of</strong> 70 patients.<br />
Int J Cancer 1997; 74: 212-219<br />
9 Sanders DS, Bruton R, Darnton SJ, Casson AG, Hanson I,<br />
Williams HK, Jankowski J. Sequential changes in cadherincatenin<br />
expression associated with the progression and<br />
heterogeneity <strong>of</strong> primary oesophageal squamous carcinoma.<br />
Int J Cancer 1998; 79: 573-579<br />
10 Bian YS, Osterheld MC, Bosman FT, Fontolliet C, Benhattar J.<br />
Nuclear accumulation <strong>of</strong> beta-catenin is a common and early<br />
event during neoplastic progression <strong>of</strong> Barrett esophagus. Am<br />
J Clin Pathol 2000; 114: 583-590<br />
11 Wijnhoven BP, Nollet F, De Both NJ, Tilanus HW, Dinjens<br />
WN. Genetic alterations involving exon 3 <strong>of</strong> the beta-catenin<br />
gene do not play a role in adenocarcinomas <strong>of</strong> the esophagus.<br />
Int J Cancer 2000; 86: 533-537<br />
12 Gonzalez MV, Artimez ML, Rodrigo L, Lopez-Larrea C,<br />
Menendez MJ, Alvarez V, Perez R, Fresno MF, Perez MJ,<br />
Sampedro A, Coto E. Mutation analysis <strong>of</strong> the p53, APC,<br />
and p16 genes in the Barrett’s oesophagus, dysplasia, and<br />
adenocarcinoma. J Clin Pathol 1997; 50: 212-217<br />
13 Sheng H, Shao J, Williams CS, Pereira MA, Taketo MM,<br />
Oshima M, Reynolds AB, Washington MK, DuBois RN,<br />
Beauchamp RD. Nuclear translocation <strong>of</strong> beta-catenin in<br />
hereditary and carcinogen-induced intestinal adenomas.<br />
Carcinogenesis 1998; 19: 543-549<br />
14 Hourihan RN, O’Sullivan GC, Morgan JG. Transcriptional<br />
gene expression pr<strong>of</strong>iles <strong>of</strong> oesophageal adenocarcinoma and<br />
normal oesophageal tissues. Anticancer Res 2003; 23: 161-165<br />
15 Kimura Y, Shiozaki H, Doki Y, Yamamoto M, Utsunomiya T,<br />
Kawanishi K, Fukuchi N, Inoue M, Tsujinaka T, Monden M.<br />
Cytoplasmic beta-catenin in esophageal cancers. Int J Cancer<br />
1999; 84: 174-178<br />
16 Roh H, Green DW, Boswell CB, Pippin JA, Drebin JA.<br />
Suppression <strong>of</strong> beta-catenin inhibits the neoplastic growth <strong>of</strong><br />
APC-mutant colon cancer cells. Cancer Res 2001; 61: 6563-6368<br />
17 Green DW, Roh H, Pippin JA, Drebin JA. Beta-catenin<br />
antisense treatment decreases beta-catenin expression and<br />
tumor growth rate in colon carcinoma xenografts. J Surg Res<br />
2001; 101: 16-20<br />
<strong>18</strong> Yan YX, Nakagawa H, Lee MH, Rustgi AK. Transforming growth<br />
factor-alpha enhances cyclin D1 transcription through the binding<br />
<strong>of</strong> early growth response protein to a cis-regulatory element in the<br />
cyclin D1 promoter. J Biol Chem 1997; 272: 33<strong>18</strong>1-33190<br />
19 Jaattela M. Programmed cell death: many ways for cells to die<br />
decently. Ann Med 2002; 34: 480-488<br />
20 Chen S, Guttridge DC, You Z, Zhang Z, Fribley A, Mayo MW,<br />
Kitajewski J, Wang CY. Wnt-1 signaling inhibits apoptosis by<br />
activating beta-catenin/T cell factor-mediated transcription. J<br />
Cell Biol 2001; 152: 87-96<br />
S- Editor Liu Y L-Editor Wang XL E- Editor Wang HF<br />
www.wjgnet.com
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2626-2628<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
RAPID COMMUNICATION<br />
Study <strong>of</strong> the expressions <strong>of</strong> p 53 and bcl -2 genes, the<br />
telomerase activity and apoptosis in GIST patients<br />
Qiang Wang, You-Wei Kou<br />
Qiang Wang, You-wei Kou, Department <strong>of</strong> Gastrointestinal<br />
Surgery, Shenjing Hospital <strong>of</strong> China Medical University, Shenyang<br />
110004, Liaoning Province, China<br />
Correspondence to: Qiang Wang, Department <strong>of</strong> Gastrointestinal<br />
Surgery, Shenjing Hospital <strong>of</strong> China Medical University, Shenyang<br />
110004, Liaoning Province, China. kyw_781215@163.com<br />
Telephone: +86-24-83955060<br />
Received: 2007-01-17 Accepted: 2007-02-08<br />
Abstract<br />
AIM: To explore the relationship between clinicobiological<br />
behavior and the expression levels <strong>of</strong> telomerase activity,<br />
apoptosis, p 53 gene and bcl -2 gene in gastrointestinal<br />
stromal tumors (GISTs).<br />
METHODS: The intensity <strong>of</strong> telomerase activity,<br />
apoptosis, p 53 and bcl -2 expression in GISTs were<br />
detected by telomeric repeat amplification protocol, in<br />
situ end-labeling technique, and immunohistochemistry,<br />
respectively.<br />
RESULTS: The positive rates <strong>of</strong> telomerase activity <strong>of</strong><br />
malignant GIST, potential malignant GIST and benign<br />
GIST were 85% (17/20), 22.8% (2/9) and 0 (0/9),<br />
respectively. The apoptosis indices <strong>of</strong> malignant GIST,<br />
potential malignant GIST, and benign GIST were 11.7<br />
± 5.4, 30.2 ± 5.6 and 45.2 ± 7.2, respectively. The<br />
intensity <strong>of</strong> telomerase activity and apoptosis were<br />
related to the biological characteristics <strong>of</strong> GISTs (85% vs<br />
22.8%, 0, 0; P < 0.01 or 11.7 ± 5.4 vs 30.2 ± 5.6, 45.2<br />
± 7.2, 72.1 ± 9.3; P < 0.05). The intensity <strong>of</strong> telomerase<br />
activity was negatively correlated with cellular apoptosis<br />
(22.9 ± 8.4 vs 9.5 ± 5.7, P < 0.01). The intensity <strong>of</strong><br />
telomerase activity was positively correlated with p 53,<br />
bcl -2 expression (40.0% vs 78.9%, 40.0% vs 84.2%;<br />
P < 0.05).<br />
CONCLUSION: The detection <strong>of</strong> telomerase activity,<br />
apoptosis and its control genes in GIST will be helpful for<br />
the discrimination <strong>of</strong> the malignant and benign GIST and<br />
evaluation <strong>of</strong> the prognosis.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Gastrointestinal stromal tumors; Telomerase;<br />
p 53; bcl -2; Apoptosis<br />
Wang Q, Kou YW. Study <strong>of</strong> the expressions <strong>of</strong> p 53 and<br />
bcl -2 genes, the telomerase activity and apoptosis in GIST<br />
www.wjgnet.com<br />
patients. <strong>World</strong> J Gastroenterol 2007; 13(<strong>18</strong>): 2626-2628<br />
http://www.wjgnet.com/1007-9327/13/2626.asp<br />
INTRODUCTION<br />
Gastrointestinal stromal tumor (GIST) was first outlined<br />
by Mazur et al [1] in 1983. It was considered to originate<br />
from gastrointestinal submucous (SM) and musclular<br />
propria (MP) lamina, which is constructed by spindle cell<br />
and epithelial cell. GIST is classified into four phenotypes<br />
according to differentiation and immunohistochemistry,<br />
namely muscular type, neural type, mixed type and<br />
indeterminate type. The diagnosis <strong>of</strong> GIST is determined<br />
by pathological examination and the detection <strong>of</strong> certain<br />
immunohistochemical factors with special characteristics,<br />
such as CD117 or C-kit and CD34. Investigations on<br />
GIST have increased greatly these years [1-7] . This study<br />
aimed to explore the relationship between clinicobiological<br />
behavior and the expression levels <strong>of</strong> telomerase activity,<br />
apoptosis, p53 gene and bcl-2 gene in GISTs.<br />
MATERIALS AND METHODS<br />
Subjects<br />
A total <strong>of</strong> 38 GIST patients (23 men and 15 women,<br />
with mean age <strong>of</strong> 52.6 years), who underwent surgical<br />
resection from 1996 to 2006 in the 2 nd Affiliated Hospital<br />
<strong>of</strong> China Medical University, were enrolled in this study.<br />
The locations <strong>of</strong> the tumors were in the stomach (n = 17,<br />
44.7%), small intestine (n = 11, 28.9%), colon and rectum<br />
(n = 10, 26.4%). The immunohistochemical factors CD117<br />
and CD34 were detected in the specimens. According<br />
to the classification <strong>of</strong> Ji et al [8] , the 38 GIST specimens<br />
were classified into benign GIST (n = 9, 23.7%), potential<br />
malignant GIST (n = 9, 23.7%), and malignant GIST<br />
(n = 20, 52.6%). Another 10 specimens <strong>of</strong> normal smooth<br />
muscle tissue (NSMT) were selected as control group,<br />
5 <strong>of</strong> which were from the stomach and the others were<br />
from the intestine. Each specimen was divided in two<br />
parts, one <strong>of</strong> which was stored at -80℃, and the others<br />
were embedded in paraffin blocks and cut into 5-μm thick<br />
sections.<br />
Telomerase activity detection<br />
According to manual, 30-50 mg tissue was sheared into<br />
small particles. After schizolysis and centrifugation,
Wang Q et al . p 53 and bcl -2, telomerase activity, and apoptosis in GIST 2627<br />
Table 1 The expression level <strong>of</strong> telomerase and AI in tissue<br />
NSMT and GIST<br />
Patients n Negative telomerase<br />
n (%)<br />
AI (mean ± SD)<br />
NSMT 10 - 72.1 ± 9.3<br />
Benign GIST 9 - 45.2 ± 7.2<br />
Potential malignant GIST 9 2 (22.8) 30.2 ± 5.6<br />
Malignant GIST 20 17 (85.0) 11.7 ± 5.4<br />
the supernatant was kept as templates in the following<br />
PCR amplification. Twenty-five microliters <strong>of</strong> TRAP<br />
mixture, 0.5 μL <strong>of</strong> reverse primer (primer sequence:<br />
5’-AATCCGTCGAGCAGAGTT-3’), 0.2 μL <strong>of</strong> Taq<br />
polymerase and 1 μL <strong>of</strong> supernatant were mixed and<br />
kept at 30℃ for 30 min as the PCA reaction system.<br />
Amplification was carried out with a Perkin-Elmer DNA<br />
Thermal Cycler 480. The conditions for amplification<br />
were 94℃ for 4 min, followed by 30 amplification cycles<br />
at 94℃ for 30 s, 35℃ for 30 s, and 72℃ for 30 s. The 30<br />
cycles were followed by a single extension cycle at 72℃ for<br />
10 min. PCR products were electrophoresed on 120 mg/L<br />
polyacrylamide gel stained by silver nitrate. “scaliform”<br />
zone appeared in the telomerase positive result.<br />
Cell apoptosis detection<br />
Tumor tissue sections were stained with terminal<br />
deoxynucleotidyl transferase (TdT)-mediated dUTP nick<br />
end labeling (TUNEL) to identify apoptotic cells. Briefly,<br />
the slide was firstly processed with 0.1 g/L polylysine, the<br />
sections were deparaffinized and rehydrated before treating<br />
with proteinase K (20 mg/L in 10 mmol/L Tris, pH 8.0)<br />
at 37℃ for 15 min and washed with 1 × TBS (20 mmol/L<br />
Tris, pH 7.6, 140 mmol/L NaCl). After inactivation <strong>of</strong><br />
endogenous peroxidase, sections were rinsed in TdT<br />
buffer (30 mmol/L Tris, 140 mmol/L sodium cacodylate,<br />
1 mmol/L cobalt chloride, pH 7.2) and incubated with<br />
TdT at a 1:50 dilution and biotinylated dUTP at a 1:50<br />
dilution in TdT buffer for 60 min at room temperature.<br />
The visualization for reaction products was performed<br />
with DAB for 10 min at room temperature, counterstained<br />
with hematoxylin. Specific positive tissue sections were<br />
used for negative controls by replacing the TdT with PBS<br />
in the reaction mixture. The positive staining was defined<br />
as light yellow to brown stain in the cytoplasm or nuclei.<br />
We selected 10 visual fields in each slide, and counted 1000<br />
cells in every visual field. The apoptotic index (AI) = (total<br />
number <strong>of</strong> positive cells/1000) × 100%.<br />
Detection <strong>of</strong> p53 gene and Bcl-2 gene<br />
Immunohistochemical staining <strong>of</strong> p53, bcl-2 was performed<br />
with a standard avidin-biotin-peroxidase complex<br />
detection kit according to the manufacturer’s instructions.<br />
p53 was located in the nuclei, while bcl-2 was located in the<br />
cytoplasm as light yellow to brown color. The expression<br />
was considered positive if the number <strong>of</strong> stained cells ><br />
20% <strong>of</strong> the total cells in a slide.<br />
Statistical analysis<br />
Data were analyzed using the χ 2 test and Student’s t test,<br />
Table 2 Relationship between telomerase activity, AI,<br />
expression level <strong>of</strong> p 53 and bcl -2 in GIST tissues (n = 9)<br />
Telomerase group AI (mean ± SD) p 53 (-) rate bcl -2 (-) rate<br />
Negative 9.5 ± 5.7 b<br />
78.9% a<br />
Positive 22.9 ± 8.4 40.0% 40.0%<br />
a P < 0.05, b P < 0.01 vs Negative group.<br />
when appropriate. P < 0.05 was considered statistically<br />
significant.<br />
RESULTS<br />
The expression level <strong>of</strong> telomerase in the specimens from<br />
malignant GIST patients were significantly higher than<br />
those from potential malignant GIST patients, benign<br />
GIST patients and normal smooth muscle tissue (NSMT)<br />
(P < 0.01). AI was found to be gradually decreased in the<br />
specimens from NSMT, benign GIST, potential malignant<br />
GIST and malignant GIST patients (P < 0.05) (Table 1).<br />
The AI in the telomerase-positive group was significantly<br />
lower than that in the telomerase-negative group (P < 0.01).<br />
The expression levels <strong>of</strong> p53 and bcl-2 in the telomerasepositive<br />
group were both higher than those in the<br />
telomerase-negative group (P < 0.05) (Table 2).<br />
DISCUSSION<br />
84.2% a<br />
Telomerase is a unique rib nucleoprotein that can<br />
synthesize telomeric DNA onto chromosomal ends as a<br />
template to compensate for the loss <strong>of</strong> telomeric repeats<br />
caused by the so-called “end-replication” problem [9-13] . A<br />
recent study demonstrated that most <strong>of</strong> malignant tumors<br />
showed telomerase activity [14-<strong>18</strong>] , while normal somatic<br />
tissues and benign tumors were deprived <strong>of</strong> this property,<br />
except some germinal cells, hematopoietic stem cells and<br />
greminative layer cells [19-23] . The characteristics <strong>of</strong> the<br />
telomerase described above make it to be a significant<br />
index in cancer diagnosis and treatment than any other<br />
tumor markers used before. Few studies were carried on<br />
the relationship between the telomerase and GIST. In our<br />
study, 17 <strong>of</strong> 20 (85%) malignant GIST specimens were<br />
found to be telomerase-positive, which is in agreement<br />
with Shay et al [15] . It was suggested that telomerase would<br />
be an ideal marker for the diagnosis <strong>of</strong> malignant GIST.<br />
There were three malignant GIST specimens found to<br />
be telomerase-negative. It could not be excluded that<br />
the negative results were caused by the “telomerase para<br />
pathway” mechanism or the insufficient retraction <strong>of</strong><br />
telomere which could not activate the expression <strong>of</strong><br />
telomerase [16,17] . Two <strong>of</strong> nine potential malignant GIST<br />
specimens were also detected telomerase-positive. After<br />
necessary repeated trials, the consistent positive results<br />
excluded the possibility <strong>of</strong> false-positive result. These<br />
two patients should be followed for further malignant<br />
canceration. The results <strong>of</strong> our study showed that the<br />
detection <strong>of</strong> telomerase activity might be an artifice to<br />
discriminate the malignant and benign GIST.<br />
Apoptosis, also called as programmed cell death, is<br />
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2628 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
characterized by the generation <strong>of</strong> fragmented nuclei with<br />
highly condensed chromatin, protrusion <strong>of</strong> cytoplasm,<br />
and formation <strong>of</strong> apoptotic bodies. It is a process <strong>of</strong><br />
cell-killing mechanism to keep homeostasis through the<br />
control <strong>of</strong> gene in physiological or pathological condition.<br />
Apoptosis plays an important role in keeping the normal<br />
conformation and function <strong>of</strong> tissues and organs. If<br />
certain gene mutations cause the apoptosis regulator<br />
decreasing, the cell mutated will survive and hyperplasia<br />
resulting in tumor for mation will happen. Some<br />
researchers [24-30] have determined that apoptosis is tightly<br />
related to the development <strong>of</strong> tumors. Our study showed<br />
that there was significant negative correlation between<br />
apoptosis and the degree <strong>of</strong> GIST differentiation.<br />
The telomere decurtates along with the mitosis. But<br />
when the telomere decurtates to some extent, apoptosis<br />
will occur due to the loss <strong>of</strong> the ability <strong>of</strong> mitosis. On the<br />
other hand, the telomerase in the cell might be activated,<br />
which would make the function <strong>of</strong> telomere recovered [31] .<br />
In our study, a remarkably negative correlation was<br />
observed between the telomerase activity <strong>of</strong> GIST and<br />
apoptosis. Moreover, a positive correlation was found<br />
between the telomerase activity and the expression level <strong>of</strong><br />
p53 and bcl-2 genes. Our conclusion is consistent to some<br />
previous reports [17,21] , while opposite to others [22,23] .<br />
In summary, the detection <strong>of</strong> telomerase activity,<br />
apoptosis and its control genes in GIST will be helpful<br />
for the discrimination <strong>of</strong> the malignant and benign GIST<br />
and evaluation <strong>of</strong> the prognosis. It would be a potential<br />
method for screening <strong>of</strong> a suitable therapeutic regimen<br />
specific to GIST to make telomerase or apoptosis as a<br />
curative target. More work should be done for further<br />
research on it.<br />
REFERENCES<br />
1 Mazur MT, Clark HB. Gastric stromal tumors. Reappraisal <strong>of</strong><br />
histogenesis. Am J Surg Pathol 1983; 7: 507-519<br />
2 Wan DS. Improve the diagnosis and treatment <strong>of</strong> gastric<br />
stromal tumors. Zhonghua Weichang Waike Zazhi 2003; 6:<br />
285-287<br />
3 Wan DS, Wu XJ, Liang XM, Luo RZ, Pan ZZ, Chen G, Lu<br />
ZH, Ding PR. Surgery treatment <strong>of</strong> gastric stromal tumors.<br />
Zhonghua Weichang Waike Zazhi 2003; 6: 292-294<br />
4 Zhang CW, Zhao DJ, Zhou SC, Qiu HS. Diagnosis and<br />
treatment <strong>of</strong> gastric stromal tumors. Zhonghua Weichang Waike<br />
Zazhi 2003; 6: 288-291<br />
5 Zhang S, Wan DS. Progress <strong>of</strong> gastric stromal tumors<br />
diagnosis and treatment. Zhonghua Weichang Waike Zazhi 2003;<br />
6: 347-349<br />
6 Yan H, Marchettini P, Acherman YI, Gething SA, Brun E,<br />
Sugarbaker PH. Prognostic assessment <strong>of</strong> gastrointestinal<br />
stromal tumor. Am J Clin Oncol 2003; 26: 221-228<br />
7 Kitamura Y, Hirota S, Nishida T. Gastrointestinal stromal<br />
tumors (GIST): a model for molecule-based diagnosis and<br />
treatment <strong>of</strong> solid tumors. Cancer Sci 2003; 94: 315-320<br />
8 Ji XL, Zhao HL. New recognization <strong>of</strong> gastrointestial stromal<br />
tumors. Shijie Huaren Xiaohua Zazhi 1998; 6; 625-627<br />
9 Fang XM, Yu JP, Luo HS. The relationship <strong>of</strong> hTeRT, P16<br />
expression and telomerase activity in carcinoma <strong>of</strong> large<br />
intestine. Shijie Huaren Xiaohua Zazhi 2002; 10: 12-14<br />
www.wjgnet.com<br />
10 Yang SM, Fang DQ, Yang JL, Luo YH, Lu R, Liu WW. The<br />
effect <strong>of</strong> hTRT antisense gene on expression <strong>of</strong> gastric cancer<br />
telomerase and apoptosis related genes. Shijie Huaren Xiaohua<br />
Zazhi 2002; 10: 149-152<br />
11 Li GX, Li GQ, Zhao CZ, Xu GL. the relationship <strong>of</strong> telomerase<br />
hTRT and antioncogene P53 and P16 expression in gastric<br />
cancer. Shijie Huaren Xiaohua Zazhi 2002; 10: 591-593<br />
12 Yu HS, Zheng GS, Sun JZ, Gao QA, Xu YX, Liu HL, Li H, Ren<br />
DX, Li SM, Huang MZ. the significance <strong>of</strong> telomerse detection<br />
in esophagus precancerous lesion. Shijie Huaren Xiaohua Zazhi<br />
2003; 11: 342-343<br />
13 Kim NW. Clinical implications <strong>of</strong> telomerase in cancer. Eur J<br />
Cancer 1997; 33: 781-786<br />
14 Dahse R, Fiedler W, Ernst G. Telomeres and telomerase:<br />
biological and clinical importance. Clin Chem 1997; 43: 708-714<br />
15 Shay JW, Bacchetti S. A survey <strong>of</strong> telomerase activity in<br />
human cancer. Eur J Cancer 1997; 33: 787-791<br />
16 Zakian VA. Life and cancer without telomerase. Cell 1997;<br />
91: 1-3<br />
17 Ma JP, Zhan WH. Telomeres and telomerase in gastrointestinal<br />
cancer. Guowai Yixue Waike Fence 1997; 14: 194-196<br />
<strong>18</strong> Nowak J, Januszkiewicz D, Lewandowski K, Nowicka-<br />
Kujawska K, Pernak M, Rembowska J, Nowak T, Wysocki J.<br />
Activity and expression <strong>of</strong> human telomerase in normal and<br />
malignant cells in gastric and colon cancer patients. Eur J<br />
Gastroenterol Hepatol 2003; 15: 75-80<br />
19 Usselmann B, Newbold M, Morris AG, Nwokolo CU.<br />
Telomerase activity and patient survival after surgery for<br />
gastric and oesophageal cancer. Eur J Gastroenterol Hepatol<br />
2001; 13: 903-908<br />
20 Goytisolo FA, Samper E, Martin-Caballero J, Finnon P,<br />
Herrera E, Flores JM, Bouffler SD, Blasco MA. Short telomeres<br />
result in organismal hypersensitivity to ionizing radiation in<br />
mammals. J Exp Med 2000; 192: 1625-1636<br />
21 Mandal M, Kumar R. Bcl-2 modulates telomerase activity. J<br />
Biol Chem 1997; 272: 14<strong>18</strong>3-14<strong>18</strong>7<br />
22 Milas M, Yu D, Sun D, Pollock RE. Telomerase activity <strong>of</strong><br />
sarcoma cell lines and fibroblasts is independent <strong>of</strong> p53 status.<br />
Clin Cancer Res 1998; 4: 1573-1579<br />
23 Oishi T, Kigawa J, Minagawa Y, Shimada M, Takahashi M,<br />
Terakawa N. Alteration <strong>of</strong> telomerase activity associated with<br />
development and extension <strong>of</strong> epithelial ovarian cancer. Obstet<br />
Gynecol 1998; 91: 568-571<br />
24 Gavrieli Y, Sherman Y, Ben-Sasson SA. Identification <strong>of</strong><br />
programmed cell death in situ via specific labeling <strong>of</strong> nuclear<br />
DNA fragmentation. J Cell Biol 1992; 119: 493-501<br />
25 Terada T, Nakanuma Y. Detection <strong>of</strong> apoptosis and expression<br />
<strong>of</strong> apoptosis-related proteins during human intrahepatic bile<br />
duct development. Am J Pathol 1995; 146: 67-74<br />
26 Tong J, Hu GL, Fan XG, Tan DM. The effect <strong>of</strong> hepatitis c<br />
viruses nuclei protein and apoptosis on HepG2 cellcycle. Shijie<br />
Huaren Xiaohua Zazhi 2003; 11: 350-352<br />
27 Liu HF, Liu WW, Fang DQ, Gao JH, Wang ZH. HP induced<br />
gastric epithelial cell apoptosis, hypertrophy and P53<br />
expression. Shijie Huaren Xiaohua Zazhi 2001; 9: 1265-1268<br />
28 Pan CJ, Liu KY. Gastric cancer hypertrophy, apoptosis and<br />
expression <strong>of</strong> contral genes. Shijie Huaren Xiaohua Zazhi 2003;<br />
11: 526-530<br />
29 Wang JM, Zhou Q, Zhou SQ. Apoptosis <strong>of</strong> hepatocytes in rat<br />
<strong>of</strong> obstructive jaundice and expression <strong>of</strong> apoptotic related<br />
genes bcl-2 and bax. Zhonghua Shiyan Waike Zazhi 2000; 17:<br />
32-33<br />
30 Yuan RW, Ding Q, Jiang HY. Pancrease cancer Bcl-2, Bax<br />
expression and cell apoptosis. Shijie Huaren Xiaohua Zazhi<br />
1999; 7: 851-854<br />
31 Wright WE, Brasiskyte D, Piatyszek MA, Shay JW. Experimental<br />
elongation <strong>of</strong> telomeres extends the lifespan <strong>of</strong> immortal normal<br />
cell hybrids. EMBO J 1996; 15: 1734-1741<br />
S- Editor Wang J L- Editor Kumar M E- Editor Che YB
A<br />
A<br />
2630 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Figure 1 Photos <strong>of</strong> patients’s tumour. Pigmented lesions (café–au-lait spots) and<br />
neur<strong>of</strong>ibromas on the anterior abdominal wall (A) and on the back region (B).<br />
m<br />
L L<br />
Figure 2 A: Axial sequential contrast-enhanced CT <strong>of</strong> the abdomen showing a<br />
well-defined heterogeneous mass consisting <strong>of</strong> an external solid area and internal<br />
cystic componenet adjacent to the anterior abdominal wall; B: the solid portions <strong>of</strong><br />
the tumor were intensely stained on contrast imaging (arrows).<br />
adjacent to the anterior abdominal wall (Figures 2A and B).<br />
Solid portions <strong>of</strong> the tumor were intensely stained on<br />
contrast imaging. Magnetic resonance imaging (MRI)<br />
revealed low and markedly high intensity areas in the tumor<br />
on T1-weighted and T2-weighted sequences, respectively<br />
(Figure 3).<br />
Laboratory examination findings were as follows:<br />
hemoglobin 8.2 g/dL, hematocrit 28.2%, platelets 763 000/<br />
mm 3 , WBC 13 900/mm 3 , erythrocyte sedimentation rate<br />
70 mm/h, creatinine 1.02 mg/dL, sodium 142 mEq/L,<br />
potassium 4.06 mmol/L, calcium 8.7 mg/dL, AST <strong>18</strong> U/L,<br />
ALT 33 U/L, total bilirubin 0.3 mg/dL, LDH 95 U/L,<br />
ALP 235 U/L, GGT 54 U/L, CRP 39.1, CA-19-9 < 0.6<br />
U/mL (normal range: 0-23), CEA 1.49 ng/mL (normal<br />
range: 0-4.6), AFP 4.9 IU/mL (normal range: 0-8.5). Fecal<br />
occult blood test was negative.<br />
Oesephagogastroduodenoscopy showed alkaline<br />
reflux gastritis and colonoscopy findings were normal.<br />
Abdominal ultrasonogram showed a mass with wall<br />
thickness <strong>of</strong> 9 cm, mimicking small intestine at the lower<br />
left quadrant. An explorative laparotomy was performed.<br />
The intra-abdominal mass was resected with the small<br />
intestine and sigmoid colon segments. Pathological gross<br />
examination showed that the tumor size was 21 cm × 13<br />
cm × 7 cm with negative margins. Its external surface was<br />
nodular and cross-section was bloody, necrotic and dirty.<br />
Immunohistochemical examination showed that vimentin<br />
and actin were positive and S100, desmin, EMA, CD34,<br />
chromogranin were negative. At a later examination CD 117<br />
was determined to be positive. The patient was diagnosed<br />
as gastrointestinal stromal tumor (Figures 4 and 5). Control<br />
computerized tomography showed peritoneal implants<br />
three months later. Imatinib mesylate (600 mg/d) was<br />
administered for 1.5 years. Later on, the dose was increased<br />
to 800 mg/d as metastasis <strong>of</strong> the liver and omentum was<br />
www.wjgnet.com<br />
B<br />
B<br />
←<br />
m<br />
←<br />
discovered. However, the progression <strong>of</strong> the metastatic<br />
lesions continued despite high dosage. The longest<br />
diameter <strong>of</strong> the lesions was 6 cm in the liver and 4 cm in<br />
the omentum. The patient started oral sunitinib, 50 mg<br />
per day for 4 consecutive weeks followed by 2 wk <strong>of</strong>f<br />
per treatment cycle. After two courses <strong>of</strong> treatment, the<br />
metastasis in the liver was decreased from 6 cm to 5 cm<br />
and in the omentum from 4 cm to 3 cm. He was continued<br />
on sunitinib treatment. After four courses, the lesions were<br />
4 cm and 2 cm, respectively. However, the number <strong>of</strong> the<br />
lesions both in the liver and omentum was not decreased<br />
while the sizes <strong>of</strong> the lesions were decreased. The patient's<br />
performance was well and the disease was accepted to be<br />
stabilized with partial response. He was still using sunitinib<br />
at the time when he was reported.<br />
DISCUSSION<br />
m<br />
Figure 3 T2-weighted<br />
MRI shows heterogeneous<br />
hyperintense cystic and<br />
solid mass adjacent to the<br />
anterior abdominal wall.<br />
Figure 4 Immunohistochemical<br />
CD117 reactivity<br />
in tumor cells (DAB, ×<br />
400).<br />
Figure 5 Spindle tumor<br />
cells with two mitoses<br />
marked with arrow (HE, ×<br />
400).<br />
GIST represents the most common mesenchymal<br />
malignancy <strong>of</strong> the gastrointestinal tract. GIST occurs<br />
predominantly in adults at a median age <strong>of</strong> 58 years but can<br />
occur at any time throughout life. The majority <strong>of</strong> GIST<br />
cases (60% to 70%) arise from stomach. These tumors<br />
bear certain histopathological similarities to a specific cell<br />
type inherent in the GI tract, known as interstitial cells<br />
<strong>of</strong> Cajal (ICC) [5] . ICCs are the unique ‘pacemaker cells’<br />
that are normally present in the myenteric plexus. CD117<br />
antigen can be detected by immunohistochemical staining<br />
as a marker. Expert pathologists can define a rare subset
2632 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
and molecular genetic study <strong>of</strong> 167 cases. Am J Surg Pathol<br />
2003; 27: 625-641<br />
11 Min KW, Balaton AJ. Small intestinal stromal tumors with<br />
skeinoid fibers in neur<strong>of</strong>ibromatosis: report <strong>of</strong> four cases with<br />
ultrastructural study <strong>of</strong> skeinoid fibers from paraffin blocks.<br />
Ultrastruct Pathol 1993; 17: 307-314<br />
12 Miettinen M, Fetsch JF, Sobin LH, Lasota J. Gastrointestinal<br />
stromal tumors in patients with neur<strong>of</strong>ibromatosis 1: a<br />
clinicopathologic and molecular genetic study <strong>of</strong> 45 cases. Am<br />
J Surg Pathol 2006; 30: 90-96<br />
13 Bagnolo F, Bonassi U, Scelsi R, Testoni PA. Gastric stromal<br />
tumour: a rare neoplasm presenting with gastrointestinal<br />
bleeding. Eur J Gastroenterol Hepatol 1998; 10: 791-794<br />
14 Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal<br />
stromal tumors: current diagnosis, biologic behavior, and<br />
management. Ann Surg Oncol 2000; 7: 705-712<br />
15 Miettinen M, Sarlomo-Rikala M, Lasota J. Gastrointestinal<br />
stromal tumors: recent advances in understanding <strong>of</strong> their<br />
biology. Hum Pathol 1999; 30: 1213-1220<br />
16 Levy AD, Patel N, Abbott RM, Dow N, Miettinen M, Sobin LH.<br />
Gastrointestinal stromal tumors in patients with neur<strong>of</strong>ibromatosis:<br />
www.wjgnet.com<br />
imaging features with clinicopathologic correlation. AJR Am J<br />
Roentgenol 2004; <strong>18</strong>3: 1629-1636<br />
17 Demetri GD, von Mehren M, Blanke CD, Van den Abbeele<br />
AD, Eisenberg B, Roberts PJ, Heinrich MC, Tuveson DA,<br />
Singer S, Janicek M, Fletcher JA, Silverman SG, Silberman<br />
SL, Capdeville R, Kiese B, Peng B, Dimitrijevic S, Druker<br />
BJ, Corless C, Fletcher CD, Joensuu H. Efficacy and safety<br />
<strong>of</strong> imatinib mesylate in advanced gastrointestinal stromal<br />
tumors. N Engl J Med 2002; 347: 472-480<br />
<strong>18</strong> Heinrich MC, Maki RG, Corless CL, Antonescu CR, Fletcher<br />
JA, Fletcher CD, Huang X, Baum CM, Demetri GD. Sunitinib<br />
(SU) response in imatinib-resistant (IM-R) GIST correlates<br />
with KIT and PDGFRA mutation status (abstract 9502). J Clin<br />
Oncol 2006; 24 suppl: 520<br />
19 Demetri GD, van Oosterom AT, Garrett CR, Blackstein ME,<br />
Shah MH, Verweij J, McArthur G, Judson IR, Heinrich MC,<br />
Morgan JA, Desai J, Fletcher CD, George S, Bello CL, Huang<br />
X, Baum CM, Casali PG. Efficacy and safety <strong>of</strong> sunitinib in<br />
patients with advanced gastrointestinal stromal tumour after<br />
failure <strong>of</strong> imatinib: a randomised controlled trial. Lancet 2006;<br />
368: 1329-1338<br />
S- Editor Liu Y L- Editor Wang XL E- Editor Chen GJ
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2633-2635<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
Ectopic fascioliasis mimicking a colon tumor<br />
Ozer Makay, Baris Gurcu, Cemil Caliskan, Deniz Nart, Muge Tuncyurek, Mustafa Korkut<br />
Ozer Makay, Baris Gurcu, Cemil Caliskan, Deniz Nart,<br />
Muge Tuncyurek, Mustafa Korkut, Ege University Hospital,<br />
Department <strong>of</strong> General Surgery, Bornova 35040 Izmir, Turkey<br />
Correspondence to: Dr. Ozer Makay, Ege University Hospital,<br />
Department <strong>of</strong> General Surgery, Bornova 35040 Izmir,<br />
Turkey. ozer.makay@ege.edu.tr<br />
Telephone: +90-232-3904020 Fax: +90-232-3398838<br />
Received: 2007-02-02 Accepted: 2007-03-08<br />
Abstract<br />
Fasciola hepatica, a leaf shaped trematode that is<br />
common in cattle, sheep and goats, is acquired by<br />
eating raw water plants like watercress or drinking<br />
water infected with the encysted form <strong>of</strong> the parasite.<br />
The varied clinical presentations <strong>of</strong> fascioliasis still<br />
make a high index <strong>of</strong> suspicion mandatory. Besides<br />
having a wide spectrum <strong>of</strong> hepatobiliary symptoms like<br />
obstructive jaundice, cholangitis and liver cirrhosis, the<br />
parasitic infection also has extrabiliary manifestations.<br />
Until recently, extrahepatic fascioliasis has been reported<br />
in the subcutaneous tissue, brain, lungs, epididymis,<br />
inguinal lymph nodes, stomach and the cecum. In this<br />
report, a strange manifestation <strong>of</strong> the fasciola infection<br />
in a site other than the liver, a colonic fascioliasis, is<br />
presented.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Fasciola hepatica; ectopic fascioliasis;<br />
Colon<br />
Makay O, Gurcu B, Caliskan C, Nart D, Tuncyurek M, Korkut<br />
M. ectopic fascioliasis mimicking a colon tumor. <strong>World</strong> J<br />
Gastroenterol 2007; 13(<strong>18</strong>): 2633-2635<br />
http://www.wjgnet.com/1007-9327/13/2633.asp<br />
INTRODUCTION<br />
Human fascioliasis is a rare encountered parasitic infection<br />
that has been reported endemic in some parts <strong>of</strong> the Far<br />
and Middle East, including Turkey [1] . Extrahepatobiliary<br />
localization <strong>of</strong> the parasite is very uncommon. Until<br />
recently, extrahepatic fascioliasis has been reported in<br />
the subcutaneous tissue [2] , brain [3] , lungs [4] , epididymis [2] ,<br />
inguinal lymph nodes [5] and in gastrointestinal system<br />
organs like the stomach [6] and the cecum [7] . Herein, we<br />
present a strange manifestation <strong>of</strong> the fasciola infection<br />
CASE REPORT<br />
in a site other than the liver. This is the second ectopic<br />
fascioliasis case mimicking a colonic tumor in the English<br />
medical literature.<br />
CASE REPORT<br />
A 55-year-old male patient was admitted to a local hospital<br />
with a 1-year history <strong>of</strong> abdominal pain worsening after<br />
meals. The patient had no history <strong>of</strong> any major illnesses.<br />
Physical examination revealed no pathology and abdominal<br />
ultrasonography (US) showed gallstones in the gallbladder.<br />
He was treated symptomatically. Despite treatment, the<br />
abdominal pain continued and an abdominal computerized<br />
tomography (CT) was carried out which revealed a 4cm<br />
× 7 cm intraluminal mass originating from the ascending<br />
colon, adjacent to the right kidney and the liver, infiltrating<br />
the pericolic fat (Figure 1). He was hospitalized for<br />
further investigation. Physical examination again revealed<br />
no pathology and laboratory findings, including liver<br />
function tests, erythrocyte sedimentation rate, white<br />
blood cell count and tumor markers, were unremarkable.<br />
Eosinophil ratio was normal. Since it was reported that the<br />
identification <strong>of</strong> the nature <strong>of</strong> the mass was not possible<br />
radiologically, a colonoscopy was planned which could<br />
not be carried out, unfortunately. During admission, the<br />
patient developed mechanical bowel obstruction and<br />
demanded immediate surgical exploration. A solid mass,<br />
originating from the right colon, 7 cm × 5 cm in diameter<br />
and invading the serosa was found during surgery. All<br />
other intraabdominal organs, including the liver, were<br />
found without particularity. Following exploration, a right<br />
hemicolectomy - ileotransversotomy and cholecystectomy<br />
was performed. The histopathological examination <strong>of</strong><br />
the colonic specimen revealed granulomas with central<br />
necrosis and Charcot Leyden crystals, surrounded by<br />
an inflammatory infiltrate with eosinophils secondary<br />
to fasciola hepatica. Trapped egg was found inside the<br />
granuloma (Figure 2). Serological examination with the<br />
indirect hemagglutination test verified fascioliasis with<br />
a titre <strong>of</strong> 1/640. The patient’s postoperative course was<br />
uneventful. Bithionol therapy was scheduled after surgery<br />
and serological examination became negative, while the<br />
follow-up abdominal tomography revealed no abnormality,<br />
after one year.<br />
DISCUSSION<br />
Fasciola hepatica, a zoonotic disease, infects a wide variety<br />
<strong>of</strong> mammalian hosts all around the world [8] . The infectious<br />
form <strong>of</strong> the trematode is the metacercaria which reaches<br />
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2634 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
Figure 1 Computerized tomography revealed a 4 cm x 7 cm intraluminal mass<br />
originating from the ascending colon, adjacent to the right kidney and the liver,<br />
infiltrating the pericolic fat.<br />
the stomach by ingestion <strong>of</strong> infected food or water. Here,<br />
the outer shell <strong>of</strong> the metacercaria melts and the young<br />
trematode becomes loose. The trematode penetrates the<br />
intestinal wall to reach the periton, stays there for a few<br />
days and climbs to the surface <strong>of</strong> the liver. It penetrates<br />
the capsule <strong>of</strong> Glisson and enters the liver parenchyma<br />
to reach the bile ducts. Another way to reach the liver<br />
parenchyma is by blood or lymphatic circulation [9,10] .<br />
The usual symptoms are fever <strong>of</strong> unknown origin,<br />
abdominal pain, biliary colic and cholangitis, which are<br />
caused by the migration <strong>of</strong> the trematode to the biliary<br />
tract [11] . As the parasite grows it can cause bleeding,<br />
necrosis and inflammation following by fibrosis <strong>of</strong> the<br />
hepatocyte [12-14] . The diagnosis is usually based upon the<br />
detection <strong>of</strong> the eggs in the duodenal aspirate and feces.<br />
Serological tests are the main diagnostic tests, which<br />
become important in especially suspicious cases. The<br />
diagnosis can be verified 95%-100% by the enzyme linked<br />
immunoabsorbent assay (ELISA) [14] . Radiological findings<br />
<strong>of</strong> fascioliasis are based mainly on US and CT [8,15] . There<br />
are recent studies reporting magnetic resonance imaging<br />
to be useful in the diagnosis <strong>of</strong> fasciola hepatica [16,17] . CT<br />
can be useful in the diagnosis and the findings can be<br />
pathognomonic in almost 90% <strong>of</strong> the patients [15] .<br />
A strange manifestation <strong>of</strong> fascioliasis is the disease in<br />
sites other than the liver. The precise route <strong>of</strong> migration<br />
toward ectopic sites is unknown, and various theories have<br />
been formulated, including the migration through blood<br />
vessels or through the s<strong>of</strong>t tissues [9,<strong>18</strong>,19] . Until recently,<br />
extrahepatic fascioliasis has been reported in foci like the<br />
subcutaneous tissue, brain, lungs, epididymis, inguinal<br />
lymph nodes, stomach and the cecum. Nevertheless, there<br />
has been only one data concerning a report <strong>of</strong> colonic<br />
fascioliasis [7] . All preoperative diagnostic work-up in the<br />
current case failed to point out the fascioliasis. Emergency<br />
surgery was performed, since a diagnosis <strong>of</strong> an obstructing<br />
colon tumor was suspected. Postoperative work-up,<br />
including the histopathological and serological assay,<br />
confirmed the presence <strong>of</strong> the parasitic disease. When<br />
reanalyzing the preoperative abdominal CT retrospectively,<br />
it was reported that the mass could be regarded as a<br />
possible inflammatory mass which could have led us to<br />
the diagnosis <strong>of</strong> a non-malignant tumor. In the eye <strong>of</strong> this<br />
knowledge, whether the management would change is a<br />
www.wjgnet.com<br />
Figure 2 Histological study shows a trapped egg (arrow) in the center <strong>of</strong> a<br />
granuloma. Eosinophilia is striking around this structure (HE, × 400).<br />
matter <strong>of</strong> debate. Another point is that we might insist on<br />
colonoscopy that could reveal differentiation <strong>of</strong> the mass.<br />
Besides, maybe an effective colonoscopy could lead to the<br />
performance <strong>of</strong> a serological test for parasitic investigation<br />
before surgery. Whether resective surgery was too radical<br />
in this case is another matter <strong>of</strong> debate.<br />
Eosinophilia in fascioliasis cases is striking and almost<br />
always present. This is usually the way most fascioliasis<br />
cases are defined during routine screening [5] . Unfortunately,<br />
this could not be dated in our patient. The presence<br />
<strong>of</strong> Eosinophilia might be a clue, resulting in a carefully<br />
diagnostic work-up to rule out the parasitosis.<br />
Since signs and symptoms <strong>of</strong> fascioliasis may be<br />
confused with a wide variety <strong>of</strong> disorders, including<br />
hepatobiliary and extrahepatobiliary, diagnosis and<br />
treatment are <strong>of</strong>ten problematic and delayed [7] . A long list<br />
<strong>of</strong> differential diagnosis is essential. Especially in countries<br />
where the disease is presumed to be endemic, a high<br />
index <strong>of</strong> suspicion is <strong>of</strong> utmost importance. It should be<br />
considered in cases from endemic areas with a history <strong>of</strong><br />
ingestion <strong>of</strong> watercress. Besides, it must be kept in mind<br />
that drinking contaminated water is also a way <strong>of</strong> acquiring<br />
the disease. Until recently, seroprevalance <strong>of</strong> the parasite<br />
in Eastern Turkey was reported to be 2.78% independent<br />
<strong>of</strong> age, educational and socioeconomic status [20] . In Turkey<br />
214 cases <strong>of</strong> fascioliasis have been reported from 1932 to<br />
2003. It is believed that the number <strong>of</strong> reported cases have<br />
increased with the use <strong>of</strong> serological methods in Turkey,<br />
which had been started after 1999 [21] .<br />
To conclude, since the clinical spectrum <strong>of</strong> fascioliasis<br />
is broad and patients may present with extrahepatic<br />
symptomatology, a high index <strong>of</strong> suspicion is required.<br />
Ectopic fascioliasis should be kept in mind and added to<br />
the differential diagnosis <strong>of</strong> colorectal tumors.<br />
REFERENCES<br />
1 Bassily S, Iskander M, Youssef FG, el-Masry N, Bawden M.<br />
Sonography in diagnosis <strong>of</strong> fascioliasis. Lancet 1989; 1: 1270-1271<br />
2 Aguirre C, Merino A, Flores M, de los Rios A. Formas<br />
aberrantes de Fasciola hepatica. Estudio de dos casos. Med<br />
Clin. (Barc) 1981; 76: 125-128<br />
3 Ruggieri F, Correa AJ, Martinez E. Cerebral distomiasis. Case<br />
report. J Neurosurg 1967; 27: 268-271<br />
4 Couraud L, Raynal J, Meunier JM, Champell A, Vergnolle M.
Makay O et al . ectopic fascioliasis in the colon 2635<br />
Un cas de distomatose pulmonaire autochtone. Rev Fr Mal<br />
Resp. 1975; 3: 579-588<br />
5 Arjona R, Riancho JA, Aguado JM, Salesa R, Gonzalez-Macias<br />
J. Fascioliasis in developed countries: a review <strong>of</strong> classic and<br />
aberrant forms <strong>of</strong> the disease. Medicine (Baltimore) 1995; 74:<br />
13-23<br />
6 Acosta-Ferreira W, Vercelli-Retta J, Falconi LM. Fasciola<br />
hepatica human infection. Histopathological study <strong>of</strong> sixteen<br />
cases. Virchows Arch A Pathol Anat Histol 1979; 383: 319-327<br />
7 Park CI, Kim H, Ro JY, Gutierrez Y. Human ectopic fascioliasis<br />
in the cecum. Am J Surg Pathol 1984; 8: 73-77<br />
8 Pulpeiro JR, Armesto V, Varela J, Corredoira J. Fascioliasis:<br />
findings in 15 patients. Br J Radiol 1991; 64: 798-801<br />
9 Yamada T, Alpers DH, Owyang C, Powell DW. Textbook <strong>of</strong><br />
gastroenterology, Volume II. Parasitic diseases: Helminths. J.B.<br />
Lippincott Company, Philadelphia, 1991: 2131-2132<br />
10 Rivero MA, Marcial MA. Biliary tract disease due to Fasciola<br />
hepatica: report <strong>of</strong> a case. Bol Asoc Med P R 1989; 81: 272-274<br />
11 King CH, Mahmoud AAF. Schistosoma and other trematodes.<br />
In: Gorbach SL, Bartlett JG, Blacklow NR, editors. Infectious<br />
diseases. Philadelphia, PA: W.B. Saunders, 1992: 2015-2021<br />
12 Takeyama N, Okumura N, Sakai Y, Kamma O, Shima Y,<br />
Endo K, Hayakawa T. Computed tomography findings <strong>of</strong><br />
hepatic lesions in human fascioliasis: report <strong>of</strong> two cases. Am J<br />
Gastroenterol 1986; 81: 1078-1081<br />
13 Barrett-Conner E. Fluke infections. In: Braude AI, editor.<br />
Infectious diseases and medical microbiology. 2nd ed.<br />
Philadelphia, PA: W. B Saunders 1986: 979-982<br />
14 Knobloch J. Human fascioliasis in Cajamarca/Peru. II.<br />
Humoral antibody response and antigenaemia. Trop Med<br />
Parasitol 1985; 36: 91-93<br />
15 Han JK, Choi BI, Cho JM, Chung KB, Han MC, Kim CW.<br />
Radiological findings <strong>of</strong> human fascioliasis. Abdom Imaging<br />
1993; <strong>18</strong>: 261-264<br />
16 Kabaalioglu A, Cubuk M, Senol U, Cevikol C, Karaali K,<br />
Apaydin A, Sindel T, Luleci E. Fascioliasis: US, CT, and MRI<br />
findings with new observations. Abdom Imaging 2000; 25:<br />
400-404<br />
17 Han JK, Han D, Choi BI, Han MC. MR findings in human<br />
fascioliasis. Trop Med Int Health 1996; 1: 367-372<br />
<strong>18</strong> Catchpole BN, Snow D. Human ectopic fascioliasis. Lancet<br />
1952; 2: 711-712<br />
19 Trudgett A, Anderson A, Hanna RE. Use <strong>of</strong> immunosorbentpurified<br />
antigens <strong>of</strong> Fasciola hepatica in enzyme immunoassays.<br />
Res Vet Sci 1988; 44: 262-263<br />
20 Kaplan M, Kuk S, Kalkan A, Demirdag K, Ozdarendeli<br />
A. Fasciola hepatica seroprevalence in the Elazig region.<br />
Mikrobiyol Bul 2002; 36: 337-342<br />
21 Yilmaz H, Godekmerdan A. Human fasciolosis in Van<br />
province, Turkey. Acta Trop 2004; 92: 161-162<br />
S- Editor Liu Y L- Editor Alpini GD E- Editor Liu Y<br />
www.wjgnet.com
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2636-2638<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
CASE REPORT<br />
Celiac disease manifested by polyneuropathy and swollen ankles<br />
Zlatko Djuric, Borislav Kamenov, Vuka Katic<br />
Zlatko Djuric, Children’s Hospital, Department <strong>of</strong> <strong>Gastroenterology</strong>,<br />
University <strong>of</strong> Nis School <strong>of</strong> Medicine, Nis, Serbia<br />
Borislav Kamenov, Children’s Hospital, Department <strong>of</strong> Immunology,<br />
University <strong>of</strong> Nis School <strong>of</strong> Medicine, Nis, Serbia<br />
Vuka Katic, Institute <strong>of</strong> Pathology, University <strong>of</strong> Nis School <strong>of</strong><br />
Medicine, Nis, Serbia<br />
Correspodence to: Zlatko Djuric, PhD, Children’s Hospital,<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, University <strong>of</strong> Nis School <strong>of</strong><br />
Medicine, Dr. Zoran Djindjic Blv. 48, Nis <strong>18</strong>000,<br />
Serbia. zldjuric@yahoo.com<br />
Telephone: +381-<strong>18</strong>-231922 Fax: +381-<strong>18</strong>-231922<br />
Received: 2007-03-10 Accepted: 2007-03-26<br />
Abstract<br />
A 27-year-old male started to have his ankles swollen<br />
during his military service. He was examined at a<br />
military hospital where electromyoneurography showed<br />
the signs <strong>of</strong> distal sensory-motor polyneuropathy with<br />
axon demyelinization and weak myopathic changes,<br />
whereas histopathological examination <strong>of</strong> gastrocnemius<br />
muscle biopsy revealed some mild and nonspecific<br />
myopathy. Besides, he was found to have subcutaneous<br />
ankle tissue edemas and hypertransaminasemia. Due<br />
to these reasons, he was dismissed from the military<br />
service and examined at another hospital where bone<br />
osteodensitometry revealed low bone mineral density<br />
<strong>of</strong> the spine. However, his medical problems were not<br />
resolved and after the second discharge from hospital<br />
he was desperately seeing doctors from time to<br />
time. Finally, at our institution he was shown to have<br />
celiac disease (CD) by positive serology (antitissue<br />
transglutaminase and antiendomysial antibodies) and<br />
small bowel mucosal histopathological examination,<br />
which showed total small bowel villous atrophy. Three<br />
months after the initiation <strong>of</strong> gluten-free diet, his ankle<br />
edema disappeared, electromyoneurographic signs <strong>of</strong><br />
polyneuropathy improved and liver aminotransferases<br />
normalized. Good knowledge <strong>of</strong> CD extraintestinal<br />
signs and serologic screening are essential for early CD<br />
recognition and therapy.<br />
© 2007 The WJG Press. All rights reserved.<br />
Key words: Celiac; Polyneuropathy; Swollen ankles<br />
Djuric Z, Kamenov B, Katic V. Celiac disease manifested by<br />
polyneuropathy and swollen ankles. <strong>World</strong> J Gastroenterol<br />
2007; 13(<strong>18</strong>): 2636-2638<br />
http://www.wjgnet.com/1007-9327/13/2636.asp<br />
www.wjgnet.com<br />
INTRODUCTION<br />
Celiac disease (CD) is a genetically determined autoimmune<br />
enteropathy induced by gluten ingestion. CD<br />
patients can have typical symptoms (chronic diarrhea<br />
and malabsorbtion), extraintestinal symptoms, or they<br />
can be symptom-free. Extraintestinal clinical signs and<br />
symptoms can be diverse. They are increasingly recognized<br />
as common CD clinical manifestations. Neurological<br />
manifestations are estimated to occur in 7%-10% <strong>of</strong><br />
the affected patients [1,2] . Peripheral neuropathy is most<br />
commonly found among them [3] .<br />
CASE REPORT<br />
A 27-year-old male started to have edematous and painful<br />
ankles during his military service. His history revealed that<br />
a week before, he had been treated with penicillin due to<br />
his sore throat and fever. He was allergic to a bee sting.<br />
On admission to a local military hospital, he was noted<br />
to have gracile body and thoracical spine kyphoscoliosis.<br />
His ankles were edematous, pale and painful to touch.<br />
Peripheral pulses on both legs were weaker than normal.<br />
Neurological examination showed decreased sensibility<br />
to touch, pain and temperature on distal parts <strong>of</strong> both<br />
calfs. Vibration sense was preserved. Deep tendon reflexes<br />
were weaker than normal. His gait and heel-chin test were<br />
normal while Romberg sign was negative.<br />
Laboratory tests showed normal erythrocyte sedimentation<br />
rate, c-reactive protein and complete blood count<br />
values. Biochemistry revealed normal creatine kinase while<br />
alanine aminotransferase (100, normal 5-35 U/L) and<br />
aspartate aminotransferase (1<strong>18</strong>, normal 5-40 U/L) were<br />
elevated. All other liver function tests, including serum<br />
albumin, were normal. Antistreptolysin O antibodies titer,<br />
Waaler-Rose test and rheumatoid factor were negative.<br />
Urine analysis, urine proteins, and creatinine clirens were<br />
normal. Chlamydia trachomatis and mycoplasma were<br />
not detected by urethral swabs. Hepatitis Bs antigen,<br />
anti-hepatitis C viral antibodies and ELISA test on<br />
adenoviruses, cytomegalovirus, Ebstein-Barr virus and<br />
Borrellia burgdorferi were all negative. X-rays <strong>of</strong> both<br />
ankles were unremarkable. Ultrasound showed lymphoid<br />
retention in both ankles’ subcutaneous tissue regions (more<br />
visible on right ankle) without signs <strong>of</strong> inflammation<br />
in joints. Both ankles’ magnetic resonance imaging<br />
(MRI) showed diffuse edemas around the joints (more<br />
prominent on the right) without any signs <strong>of</strong> synovitis<br />
and tendonitis. Doppler ultrasound revealed normal blood<br />
flow in both legs. Electromyoneurography displayed
2638 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
associated with celiac disease in patients with inflammatory<br />
myopathy. Muscle Nerve 2007; 35: 49-54<br />
10 Marie I, Lecomte F, Hachulla E, Antonietti M, Francois A,<br />
Levesque H, Courtois H. An uncommon association: celiac<br />
disease and dermatomyositis in adults. Clin Exp Rheumatol<br />
2001; 19: 201-203<br />
11 Henriksson KG, Hallert C, Norrby K, Walan A. Polymyositis<br />
and adult coeliac disease. Acta Neurol Scand 1982; 65: 301-319<br />
12 Morris JS, Ajdukiewicz AB, Read AE. Neurological disorders<br />
and adult coeliac disease. Gut 1970; 11: 549-554<br />
13 Somay G, Cevik DM, Halac GU, Abut E, Erenoglu NY.<br />
Cobalamine deficiency associated with neuropathy and oral<br />
mucosal melanosis in untreated gluten-sensitive enteropathy.<br />
Indian J Gastroenterol 2005; 24: 120-122<br />
14 Kleopa KA, Kyriacou K, Zamba-Papanicolaou E, Kyriakides T.<br />
Reversible inflammatory and vacuolar myopathy with vitamin<br />
E deficiency in celiac disease. Muscle Nerve 2005; 31: 260-265<br />
15 Chin RL, Sander HW, Brannagan TH, Green PH, Hays AP,<br />
Alaedini A, Latov N. Celiac neuropathy. Neurology 2003; 60:<br />
1581-1585<br />
16 Korponay-Szabo IR, Halttunen T, Szalai Z, Laurila K, Kiraly R,<br />
Kovacs JB, Fesus L, Maki M. In vivo targeting <strong>of</strong> intestinal and<br />
extraintestinal transglutaminase 2 by coeliac autoantibodies.<br />
Gut 2004; 53: 641-648<br />
17 Kaplan JG, Pack D, Horoupian D, DeSouza T, Brin M,<br />
www.wjgnet.com<br />
Schaumburg H. Distal axonopathy associated with chronic<br />
gluten enteropathy: a treatable disorder. Neurology 1988; 38:<br />
642-645<br />
<strong>18</strong> Polizzi A, Finocchiaro M, Parano E, Pavone P, Musumeci<br />
S, Polizzi A. Recurrent peripheral neuropathy in a girl with<br />
celiac disease. J Neurol Neurosurg Psychiatry 2000; 68: 104-105<br />
19 Tursi A, Giorgetti GM, Iani C, Arciprete F, Brandimarte G,<br />
Capria A, Fontana L. Peripheral neurological disturbances,<br />
autonomic dysfunction, and antineuronal antibodies in adult<br />
celiac disease before and after a gluten-free diet. Dig Dis Sci<br />
2006; 51: <strong>18</strong>69-<strong>18</strong>74<br />
20 Luostarinen L, Himanen SL, Luostarinen M, Collin P, Pirttila<br />
T. Neuromuscular and sensory disturbances in patients with<br />
well treated coeliac disease. J Neurol Neurosurg Psychiatry 2003;<br />
74: 490-494<br />
21 American Gastroenterological Association medical position<br />
statement: guidelines on osteoporosis in gastrointestinal<br />
diseases. <strong>Gastroenterology</strong> 2003; 124: 791-794<br />
22 Bardella MT, Fraquelli M, Quatrini M, Molteni N, Bianchi P,<br />
Conte D. Prevalence <strong>of</strong> hypertransaminasemia in adult celiac<br />
patients and effect <strong>of</strong> gluten-free diet. Hepatology 1995; 22: 833-836<br />
23 Gonzalez-Abraldes J, Sanchez-Fueyo A, Bessa X, Moitinho<br />
E, Feu F, Mas A, Escorsell A, Bruguera M. Persistent<br />
hypertransaminasemia as the presenting feature <strong>of</strong> celiac<br />
disease. Am J Gastroenterol 1999; 94: 1095-1097<br />
S- Editor Liu Y L- Editor Ma JY E- Editor Zhou T
2640 ISSN 1007-9327 CN 14-1219/R <strong>World</strong> J Gastroenterol May 14, 2007 Volume 13 Number <strong>18</strong><br />
aminotransferases) as treatment end-points needs to be<br />
done cautiously, particularly in the absence <strong>of</strong> a control<br />
group. The natural history <strong>of</strong> patients with non-alcoholic<br />
fatty liver disease and raised aminotransferases is characterized<br />
by improvement <strong>of</strong> aminotransferases regardless<br />
<strong>of</strong> whether hepatic fibrosis improves or not [11] .<br />
Both weight loss and regular physical exercise target<br />
to improve first insulin resistance, but it can ameliorate<br />
secondarily associated metabolic conditions, namely diabetes,<br />
hyperlipemia and hypertension [10] . To achieve longstanding<br />
results, the expertise <strong>of</strong> a multidisciplinary team is<br />
required. Apart from the hepatologist, skilled dietician,<br />
endocrinologist, cardiologist, dietician, psychologist and<br />
radiologist enter a well-designed case management system to<br />
ensure the best therapeutic approach for each patient [12] .<br />
Lifestyle advice is <strong>of</strong> benefit to improve levels <strong>of</strong><br />
aminotransferases [10,13] , inflammation and steatosis in both<br />
children (unpublished data) and adults [13] . As far as fibrosis<br />
concerns, in a two-year double-blind controlled study,<br />
we have observed that fibrosis does not ameliorate in<br />
children either compliant to the nutritional program or to<br />
the supplementation with 600 g/d vitamin E (unpublished<br />
data). On the other hand, in adult NAFLD, fibrosis has<br />
been proved to be reduced after weight loss only in 50%<br />
<strong>of</strong> subjects compliant to the diet, who had higher levels<br />
<strong>of</strong> insulin at the baseline and greater decrease <strong>of</strong> ALT<br />
during the follow-up as compared with patients with<br />
lower hyperinsulinemia at the enrolment and a modest<br />
decrease <strong>of</strong> liver enzyme throughout the study period [13] .<br />
Effects <strong>of</strong> drugs reducing blood lipids (i.e. fen<strong>of</strong>ibrates<br />
or orlistat) have not been exhaustively investigated<br />
either in adults or children, despite these medications<br />
may reduce fatty overload to the liver, lipid peroxidation<br />
and insulin resistance with low cost and acceptable side<br />
effects. On the contrary, attention has been paid to the<br />
effect <strong>of</strong> antioxidant agents, specifically alpha-tocopherol,<br />
and insulin-sensitizer agents, such as metformin,<br />
both medications being safe, easy to be managed and<br />
inexpensive. The pilot study by Levine [14] encouraged<br />
studies in children [15,16] and adults [17,<strong>18</strong>] , but in a recent<br />
double-blind placebo study we observed that a 1-year<br />
supplementation with vitamin E is not better than diet and<br />
physical exercise in amelioration biochemical parameters in<br />
children [16] . Unfortunately, our clinical experience suggests<br />
that the anti-oxidant molecule is not able to affect liver<br />
histology as compared with placebo (unpublished data).<br />
Data on metformin are promising too in the treatment<br />
<strong>of</strong> adult NAFLD [<strong>18</strong>,19] , but a pilot study alone has been<br />
conducted in ten children for six months and no result<br />
has been provided on histology [20] . With great expectation,<br />
we are waiting for the results <strong>of</strong> two large controlled trial<br />
sponsored by the National Institute <strong>of</strong> Health with the<br />
aim to evaluate the effect <strong>of</strong> metformin vs vitamin E or<br />
placebo on liver enzymes in <strong>18</strong>0 biopsy-proven NAFLD<br />
children [21] or those <strong>of</strong> pioglitazone vs vitamin E or placebo<br />
on liver histology <strong>of</strong> 240 adult NASH (PIVENS clinical<br />
trial) [22] . The new frontier for the treatment <strong>of</strong> NASH may<br />
be the thiazolidinediones (TZD). Pioglitazone (45 mg/d)<br />
was administered in dieting NASH patients with impaired<br />
glucose tolerance or overt type 2 diabetes mellitus for six<br />
months [23] . In the TZD treated group, the drug significantly<br />
www.wjgnet.com<br />
improved liver enzymes, steatosis, necroinflammation and<br />
ballooning in liver histology. However, the drug seems not<br />
to reduce liver fibrosis causes warning side effects, and is<br />
expensive as compared to metformin.<br />
In conclusion, any attempt to treat pharmacologically<br />
pediatric NAFLD has failed and even though the use <strong>of</strong><br />
anti-oxidants (including vitamin E or ursodeoxycholic<br />
acid) or metformin seems to be safe and not so expensive,<br />
there is no rationale to prescribe these medications unless<br />
conclusive results are provided to support their use. On the<br />
contrary, as it has been widely done for pediatric obesity,<br />
national organizations that provide health care must<br />
enhance consciousness <strong>of</strong> the disease among paediatricians<br />
and general health care providers in schools and families to<br />
favour healthy life-style, low-fat diet and physical exercise.<br />
Diet and regular physical activity remain reasonable and<br />
effective therapeutic approaches to pediatric NAFLD also<br />
in non-obese patients.<br />
REFERENCES<br />
1 Patton HM, Sirlin C, Behling C, Middleton M, Schwimmer JB,<br />
Lavine JE. Pediatric nonalcoholic fatty liver disease: a critical<br />
appraisal <strong>of</strong> current data and implications for future research.<br />
J Pediatr Gastroenterol Nutr 2006; 43: 413-427<br />
2 Strauss RS, Barlow SE, Dietz WH. Prevalence <strong>of</strong> abnormal<br />
serum aminotransferase values in overweight and obese<br />
adolescents. J Pediatr 2000; 136: 727-733<br />
3 Park HS, Han JH, Choi KM, Kim SM. Relation between elevated<br />
serum alanine aminotransferase and metabolic syndrome in<br />
Korean adolescents. Am J Clin Nutr 2005; 82: 1046-1051<br />
4 Tominaga K, Kurata JH, Chen YK, Fujimoto E, Miyagawa<br />
S, Abe I, Kusano Y. Prevalence <strong>of</strong> fatty liver in Japanese<br />
children and relationship to obesity. An epidemiological<br />
ultrasonographic survey. Dig Dis Sci 1995; 40: 2002-2009<br />
5 Schwimmer JB, McGreal N, Deutsch R, Finegold MJ, Lavine<br />
JE. Influence <strong>of</strong> gender, race, and ethnicity on suspected fatty<br />
liver in obese adolescents. Pediatrics 2005; 115: e561-e565<br />
6 Chan DF, Li AM, Chu WC, Chan MH, Wong EM, Liu EK, Chan<br />
IH, Yin J, Lam CW, Fok TF, Nelson EA. Hepatic steatosis in<br />
obese Chinese children. Int J Obes Relat Metab Disord 2004; 28:<br />
1257-1263<br />
7 Guzzaloni G, Grugni G, Minocci A, Moro D, Morabito F. Liver<br />
steatosis in juvenile obesity: correlations with lipid pr<strong>of</strong>ile,<br />
hepatic biochemical parameters and glycemic and insulinemic<br />
responses to an oral glucose tolerance test. Int J Obes Relat<br />
Metab Disord 2000; 24: 772-776<br />
8 Franzese A, Vajro P, Argenziano A, Puzziello A, Iannucci<br />
MP, Saviano MC, Brunetti F, Rubino A. Liver involvement in<br />
obese children. Ultrasonography and liver enzyme levels at<br />
diagnosis and during follow-up in an Italian population. Dig<br />
Dis Sci 1997; 42: 1428-1432<br />
9 Nadeau KJ, Klingensmith G, Zeitler P. Type 2 diabetes<br />
in children is frequently associated with elevated alanine<br />
aminotransferase. J Pediatr Gastroenterol Nutr 2005; 41: 94-98<br />
10 Nobili V, Marcellini M, Devito R, Ciampalini P, Piemonte F,<br />
Comparcola D, Sartorelli MR, Angulo P. NAFLD in children:<br />
a prospective clinical-pathological study and effect <strong>of</strong> lifestyle<br />
advice. Hepatology 2006; 44: 458-465<br />
11 Adams LA, Sanderson S, Lindor KD, Angulo P. The histological<br />
course <strong>of</strong> nonalcoholic fatty liver disease: a longitudinal study<br />
<strong>of</strong> 103 patients with sequential liver biopsies. J Hepatol 2005; 42:<br />
132-138<br />
12 Nobili V, Manco M, Raponi M, Marcellini M. Case Management<br />
applied in a multispecialist paediatric outpatients clinic for<br />
patients affected by non alcoholic fatty liver disease (NAFLD). J<br />
Paediatr Child Health 2007; 43: 414<br />
13 Hickman IJ, Jonsson JR, Prins JB, Ash S, Purdie DM, Clouston<br />
AD, Powell EE. Modest weight loss and physical activity
Nobili V et al . Therapy For Paediatric Nafld 2641<br />
in overweight patients with chronic liver disease results in<br />
sustained improvements in alanine aminotransferase, fasting<br />
insulin, and quality <strong>of</strong> life. Gut 2004; 53: 413-419<br />
14 Lavine JE. Vitamin E treatment <strong>of</strong> nonalcoholic steatohepatitis<br />
in children: a pilot study. J Pediatr 2000; 136: 734-738<br />
15 Vajro P, Mandato C, Franzese A, Ciccimarra E, Lucariello<br />
S, Savoia M, Capuano G, Migliaro F. Vitamin E treatment in<br />
pediatric obesity-related liver disease: a randomized study. J<br />
Pediatr Gastroenterol Nutr 2004; 38: 48-55<br />
16 Nobili V, Manco M, Devito R, Ciampalini P, Piemonte F,<br />
Marcellini M. Effect <strong>of</strong> vitamin E on aminotransferase levels<br />
and insulin resistance in children with non-alcoholic fatty liver<br />
disease. Aliment Pharmacol Ther 2006; 24: 1553-1561<br />
17 Harrison SA, Torgerson S, Hayashi P, Ward J, Schenker S.<br />
Vitamin E and vitamin C treatment improves fibrosis in patients<br />
with nonalcoholic steatohepatitis. Am J Gastroenterol 2003; 98:<br />
2485-2490<br />
<strong>18</strong> Bugianesi E, Gentilcore E, Manini R, Natale S, Vanni E,<br />
Villanova N, David E, Rizzetto M, Marchesini G. A randomized<br />
controlled trial <strong>of</strong> metformin versus vitamin E or prescriptive<br />
diet in nonalcoholic fatty liver disease. Am J Gastroenterol 2005;<br />
100: 1082-1090<br />
19 Marchesini G, Brizi M, Bianchi G, Tomassetti S, Zoli M,<br />
Melchionda N. Metformin in non-alcoholic steatohepatitis.<br />
Lancet 2001; 358: 893-894<br />
20 Schwimmer JB, Middleton MS, Deutsch R, Lavine JE. A phase<br />
2 clinical trial <strong>of</strong> metformin as a treatment for non-diabetic<br />
paediatric non-alcoholic steatohepatitis. Aliment Pharmacol<br />
Ther 2005; 21: 871-879<br />
21 Lavine JE, Schwimmer JB. Clinical Research Network launches<br />
TONIC trial for treatment <strong>of</strong> nonalcoholic fatty liver disease in<br />
children. J Pediatr Gastroenterol Nutr 2006; 42: 129-130<br />
22 Available from: URL: www.nih.gov/news/pr/apr2005/<br />
niddk-01.htm<br />
23 Belfort R, Harrison SA, Brown K, Darland C, Finch J, Hardies<br />
J, Balas B, Gastaldelli A, Tio F, Pulcini J, Berria R, Ma JZ,<br />
Dwivedi S, Havranek R, Fincke C, DeFronzo R, Bannayan GA,<br />
Schenker S, Cusi K. A placebo-controlled trial <strong>of</strong> pioglitazone<br />
in subjects with nonalcoholic steatohepatitis. N Engl J Med<br />
2006; 355: 2297-2307<br />
S- Editor Wang J L- Editor Ma JY E- Editor Liu Y<br />
www.wjgnet.com
Jain P et al . Insulin and heparin for HTG-induced pancreatitis 2643<br />
pancreatitis related to hypertriglyceridaemia. Anaesth Intensive<br />
Care 1999; 27: 117<br />
3 Fortson MR, Freedman SN, Webster PD 3rd. Clinical<br />
assessment <strong>of</strong> hyperlipidemic pancreatitis. Am J Gastroenterol<br />
1995; 90: 2134-2139<br />
4 Baggio G, Manzato E, Gabelli C, Fellin R, Martini S, Enzi<br />
GB, Verlato F, Baiocchi MR, Sprecher DL, Kashyap ML.<br />
Apolipoprotein C-II deficiency syndrome. Clinical features,<br />
lipoprotein characterization, lipase activity, and correction <strong>of</strong><br />
hypertriglyceridemia after apolipoprotein C-II administration<br />
in two affected patients. J Clin Invest 1986; 77: 520-527<br />
5 Monga A, Arora A, Makkar RP, Gupta AK. Hypertriglyceridemiainduced<br />
acute pancreatitis--treatment with heparin and insulin.<br />
Indian J Gastroenterol 2003; 22: 102-103<br />
S- Editor Liu Y L- Editor Ma JY E- Editor Liu Y<br />
www.wjgnet.com
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www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
wjg@wjgnet.com © 2007 The WJG Press. All rights reserved.<br />
ACKNOWLEDGMENTS<br />
Acknowledgments to Reviewers <strong>of</strong> <strong>World</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Gastroenterology</strong><br />
Many reviewers have contributed their expertise and time<br />
to the peer review, a critical process to ensure the quality<br />
<strong>of</strong> <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong>. The editors and authors<br />
<strong>of</strong> the articles submitted to the journal are grateful to the<br />
following reviewers for evaluating the articles (including<br />
those published in this issue and those rejected for this<br />
issue) during the last editing time period.<br />
Jay Pravda, MD<br />
Inflammatory Disease Research Center, Gainesville, Florida, 32614-2<strong>18</strong>1,<br />
United States<br />
Chris Jacob Johan Mulder, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, VU University Medical Center, PO Box 7057,<br />
1007 MB Amsterdam, The Netherlands<br />
Giovanni D De Palma, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> Surgery and Advanced Technologies, University <strong>of</strong> Naples<br />
Federico II, School <strong>of</strong> Medicine, Naples 80131, Italy<br />
Jose Castellote, PhD<br />
Universitari de Bellvitge. L’Hospitalet de Llobregat Barcelona. C/ Feixa Llarga<br />
S/N, L'hospitalet de Llobregat Barcelona 08023, Spain<br />
Martin Hennenberg, Dipl-Biol<br />
Medizinische Klinik & Poliklinik I, Uni-Klinik Bonn, Sigmund-Freud Str. 25,<br />
53105 Bonn, Germany<br />
Yoshiaki Iwasaki, Dr<br />
Department <strong>of</strong> <strong>Gastroenterology</strong> and Hepatology, Okayama University Graduate<br />
School <strong>of</strong> Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho,<br />
Okayama 700-8558, Japan<br />
Richard A Rippe, Dr<br />
Department <strong>of</strong> Medicine, The University <strong>of</strong> North Carolina at Chapel Hill,<br />
Chapel Hill, NC 27599-7038, United States<br />
Takafumi Ando, MD, PhD<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, Nagoya University Graduate School <strong>of</strong><br />
Medicine, Therapeutic Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550,<br />
Japan<br />
Vasiliy I. Reshetnyak, MD, PhD, Pr<strong>of</strong>essor<br />
Scientist Secretary <strong>of</strong> the Scientific Research Institute <strong>of</strong> General Reanimatology,<br />
25-2, Petrovka str., 107031, Moscow, Russia<br />
Khek-Yu Ho, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> Medicine, National University Hospital, 119074, Singapore<br />
Markus W Büchler, MD<br />
Department <strong>of</strong> General Surgery, University <strong>of</strong> Heidelberg, Im Neuenheimer Feld<br />
110, Heidelberg D-69120, Germany<br />
Masato Kusunoki, Pr<strong>of</strong>essor and Chairman<br />
Second Department <strong>of</strong> Surgery, Mie University School <strong>of</strong> Medicine, Mie, 2-174<br />
Edobashi, Tsu MIE 514-8507, Japan<br />
Walter Edwin Longo, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> Surgery, Yale University School <strong>of</strong> Medicine, 205 Cedar Street,<br />
New Haven 06510, United States<br />
Leonidas G Koniaris, Pr<strong>of</strong>essor<br />
Alan Livingstone Chair in Surgical Oncology, 3550 Sylvester Comprehensive<br />
Cancer Center (310T), 1475 NW 12th Ave., Miami, FL 33136, United States<br />
Paul Jonathan Ciclitira, Pr<strong>of</strong>essor<br />
The Rayne Institute (GKT), St Thomas’ hospital, London NW32QG,<br />
United Kingdom<br />
Yvan Vandenplas, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> Pediatrics, AZ-VUB, Laarbeeklaan 101, Brussels 1090, Belgium<br />
David R Gretch, MD, PhD<br />
Viral Hepatitis Laboratory, Room 706, UW Research and Training Building,<br />
Harborview Medical Center, Box 359690, 325 Ninth Avenue, Seattle, Washington<br />
98104, United States<br />
Patricia F Lalor, Dr<br />
Liver Research Laboratory, Room 537 Institute <strong>of</strong> Biomedical Research, Divsion<br />
<strong>of</strong> Medical Science, University <strong>of</strong> Birmingham, Birmingham B15 2TT,<br />
United Kingdom<br />
Bart Rik De Geest, Dr<br />
Center for Molecular and Vascular Biology, Katholieke Universiteit Leuven,<br />
Campus Gasthuisberg, Herestraat 49, Leuven 3000, Belgium<br />
Masatoshi Makuuchi, Pr<strong>of</strong>essor<br />
Department <strong>of</strong> Surgery, Graduate School <strong>of</strong> Medicine, University <strong>of</strong> Tokyo, T<br />
Hepato-Biliary-Pancreatic Surgery Division Tokyo 113-8655, Japan<br />
Shawn David Safford, Dr<br />
Department <strong>of</strong> Surgery, Duke University Medical Center, 994 West Ocean View<br />
Avenue, Norfolk VA23503, United States<br />
Scott A. Waldman, MD, PhD, FCP<br />
Division <strong>of</strong> Clinical Pharmacology, Departments <strong>of</strong> Medicine and Biochemistry<br />
and Molecular Pharmacology, Jefferson Medical College, Thomas Jefferson<br />
University, 1100 Walnut Street, MOB Suite 813, Pennsylvania 19107, Philadelphia,<br />
United States<br />
Bo-Rong Pan, Pr<strong>of</strong>essor<br />
Outpatient Department <strong>of</strong> Oncology, The Fourth Military Medical University, 175<br />
Changle West Road,Xi’an 710032, Shaanxi Province, China<br />
Minoti Vivek Apte, Associate Pr<strong>of</strong>essor<br />
Pancreatic Research Group, South Western Sydney Clinical School, The University<br />
<strong>of</strong> New South Wales. Liverpool, NSW 2170, Australia<br />
Burton I Korelitz, MD<br />
Department <strong>of</strong> <strong>Gastroenterology</strong>, Lenox Hill Hospital, 100 East 77th Street, 3<br />
Achelis, New York, N.Y 10021, United States<br />
Ronan A Cahill<br />
Department <strong>of</strong> General Surgery, Waterford Regional Hospital, Waterford, Cork,<br />
Ireland<br />
Katri Maria Kaukinen, MD, PhD<br />
Medical School, FIN-33014 University <strong>of</strong> Tampere, Tampere, Finland<br />
Luis Rodrigo, Pr<strong>of</strong>essor<br />
<strong>Gastroenterology</strong> Service, Hospital Central de Asturias, c/ Celestino Villamil, s.n.,<br />
Oviedo 33.006, Spain<br />
Ian David Wallace, MD<br />
Shakespeare Specialist Group, <strong>18</strong>1 Shakesperare Rd, Milford, Auckland 1309,<br />
New Zealand<br />
SØren MØller, Chief Physician<br />
Department <strong>of</strong> Clinical Physiology 239, Hvidovre Hospital, Kettegaard alle 30,<br />
DK-2650 Hvidovre, Denmark<br />
Michael Trauner, Pr<strong>of</strong>essor<br />
Medical University Graz, Auenbruggerplatz 15, Graz A-8036, Austria<br />
Ming Li, Associate Pr<strong>of</strong>essor<br />
Tulane University Health Sciences Center, 1430 Tulane Ave Sl-83, New Orleans<br />
70112, United States<br />
Christa Buechler, PhD<br />
Regensburg University Medical Center, Internal Medicine I, Franz Josef Strauss<br />
Allee 11, 93042 Regensburg, Germany
PO Box 2345, Beijing 100023, China <strong>World</strong> J Gastroenterol 2007 May 14; 13(<strong>18</strong>): 2645<br />
www.wjgnet.com <strong>World</strong> <strong>Journal</strong> <strong>of</strong> <strong>Gastroenterology</strong> ISSN 1007-9327<br />
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Meetings<br />
MAJOR MEETINGS COMING<br />
UP<br />
Meeting Falk Research Workshop:<br />
Morphogenesis and Cancerogenesis<br />
<strong>of</strong> the Liver<br />
25-26 January 2007<br />
Goettingen<br />
symposia@falkfoundation.de<br />
Meeting Canadian Digestive Diseases<br />
Week (CDDW)<br />
16-20 February 2007<br />
Banff-AB<br />
cag<strong>of</strong>fice@cag-acg.org<br />
www.cag-acg.org/cddw/cddw2007.<br />
htm<br />
Meeting Falk Symposium 158:<br />
Intestinal Inflammation and<br />
Colorectal Cancer<br />
23-24 March 2007<br />
Sevilla<br />
symposia@falkfoundation.de<br />
Meeting BSG Annual Meeting<br />
26-29 March 2007<br />
Glasgow<br />
www.bsg.org.uk/<br />
NEXT 6 MONTHS<br />
Meeting 42nd Annual Meeting <strong>of</strong> the<br />
European Association for the Study<br />
<strong>of</strong> the Liver<br />
11-15 April 2007<br />
Barcelona<br />
easl2007@easl.ch<br />
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Meeting Falk Symposium 159: IBD<br />
2007 - Achievements in Research and<br />
Clinical Practice<br />
4-5 May 2007<br />
Istanbul<br />
symposia@falkfoundation.de<br />
Meeting European Society for<br />
Paediatric <strong>Gastroenterology</strong>,<br />
Hepatology and Nutrition Congress<br />
2007<br />
9-12 May 2007<br />
Barcelona<br />
espghan2007@colloquium.fr<br />
Digestive Disease Week<br />
19-24 May 2007<br />
Washington Convention Center,<br />
Washington DC<br />
Meeting Gastrointestinal Endoscopy<br />
Best Practices: Today and Tomorrow,<br />
ASGE Annual Postgraduate Course<br />
at DDW<br />
23-24 May 2007<br />
Washington-DC<br />
tkoral@asge.org<br />
Meeting ESGAR 2007 <strong>18</strong>th Annual<br />
Meeting and Postgraduate Course<br />
12-15 June 2007<br />
Lisbon<br />
fca@netvisao.pt<br />
Meeting Falk Symposium 160:<br />
Pathogenesis and Clinical Practice in<br />
<strong>Gastroenterology</strong><br />
15-16 June 2007<br />
Portoroz<br />
symposia@falkfoundation.de<br />
Meeting ILTS 13th Annual<br />
International Congress<br />
20-23 June 2007<br />
Rio De Janeiro<br />
www.ilts.org<br />
Meeting 9th <strong>World</strong> Congress on<br />
Gastrointestinal Cancer<br />
27-30 June 2007<br />
Barcelona<br />
meetings@imedex.com<br />
EVENTS AND MEETINGS IN<br />
2007<br />
Meeting Falk Research Workshop:<br />
Morphogenesis and Cancerogenesis<br />
<strong>of</strong> the Liver<br />
25-26 January 2007<br />
Goettingen<br />
symposia@falkfoundation.de<br />
Meeting Canadian Digestive Diseases<br />
Week (CDDW)<br />
16-20 February 2007<br />
Banff-AB<br />
cag<strong>of</strong>fice@cag-acg.org<br />
www.cag-acg.org/cddw/cddw2007.<br />
htm<br />
Meeting Falk Symposium 158:<br />
Intestinal Inflammation and<br />
Colorectal Cancer<br />
23-24 March 2007<br />
Sevilla<br />
symposia@falkfoundation.de<br />
Meeting BSG Annual Meeting<br />
26-29 March 2007<br />
Glasgow<br />
www.bsg.org.uk/<br />
Meeting 42nd Annual Meeting <strong>of</strong> the<br />
European Association for the Study<br />
<strong>of</strong> the Liver<br />
11-15 April 2007<br />
Barcelona<br />
easl2007@easl.ch<br />
www.easl.ch/liver-meeting/<br />
Meeting Falk Symposium 159: IBD<br />
2007 - Achievements in Research and<br />
Clinical Practice<br />
4-5 May 2007<br />
Istanbul<br />
symposia@falkfoundation.de<br />
Meeting European Society for<br />
Paediatric <strong>Gastroenterology</strong>,<br />
Hepatology and Nutrition Congress<br />
2007<br />
9-12 May 2007<br />
Barcelona<br />
espghan2007@colloquium.fr<br />
Meeting Gastrointestinal Endoscopy<br />
Best Practices: Today and Tomorrow,<br />
ASGE Annual Postgraduate Course<br />
at DDW<br />
23-24 May 2007<br />
Washington-DC<br />
tkoral@asge.org<br />
Meeting ESGAR 2007 <strong>18</strong>th Annual<br />
Meeting and Postgraduate Course<br />
12-15 June 2007<br />
Lisbon<br />
fca@netvisao.pt<br />
Meeting Falk Symposium 160:<br />
Pathogenesis and Clinical Practice in<br />
<strong>Gastroenterology</strong><br />
15-16 June 2007<br />
Portoroz<br />
symposia@falkfoundation.de<br />
Meeting ILTS 13th Annual<br />
International Congress<br />
20-23 June 2007<br />
Rio De Janeiro<br />
www.ilts.org<br />
Meeting 9th <strong>World</strong> Congress on<br />
Gastrointestinal Cancer<br />
27-30 June 2007<br />
Barcelona<br />
meetings@imedex.com<br />
Meeting 15th International Congress<br />
<strong>of</strong> the European Association for<br />
Endoscopic Surgery<br />
4-7 July 2007<br />
Athens<br />
info@eaes-eur.org<br />
congresses.eaes-eur.org/<br />
Meeting 39th Meeting <strong>of</strong> the<br />
European Pancreatic Club<br />
4-7 July 2007<br />
Newcastle<br />
www.e-p-c2007.com<br />
Meeting XXth International<br />
Workshop on Heliobacter and<br />
related bacteria in cronic degistive<br />
inflammation<br />
20-22 September 2007<br />
Istanbul<br />
www.heliobacter.org<br />
Meeting Falk Workshop: Mechanisms<br />
<strong>of</strong> Intestinal Inflammation<br />
10 October 2007<br />
Dresden<br />
symposia@falkfoundation.de<br />
Meeting Falk Symposium 161: Future<br />
Perspectives in <strong>Gastroenterology</strong><br />
11-12 October 2007<br />
Dresden<br />
symposia@falkfoundation.de<br />
Meeting Falk Symposium 162: Liver<br />
Cirrhosis - From Pathophysiology to<br />
Disease Management<br />
13-14 October 2007<br />
Dresden<br />
symposia@falkfoundation.de<br />
American College <strong>of</strong><br />
<strong>Gastroenterology</strong> Annual Scientific<br />
Meeting<br />
12-17 October 2007<br />
Pennsylvania Convention Center<br />
Philadelphia, PA<br />
Meeting APDW 2007 - Asian Pacific<br />
Digestive Disease Week 2007<br />
15-<strong>18</strong> October 2007<br />
Kobe<br />
apdw@convention.co.jp<br />
www.apdw2007.org<br />
15th United European<br />
<strong>Gastroenterology</strong> Week, UEGW<br />
27-31 October 2007<br />
Le Palais des Congrès de Paris, Paris,<br />
France<br />
Meeting The Liver Meeting ® 2007 -<br />
57th Annual Meeting <strong>of</strong> the American<br />
Association for the Study <strong>of</strong> Liver<br />
Diseases<br />
2-6 November 2007<br />
Boston-MA<br />
www.aasld.org<br />
Gastro 2009, <strong>World</strong> Congress <strong>of</strong> <strong>Gastroenterology</strong><br />
and Endoscopy London,<br />
United Kingdom 2009
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Key words<br />
Please list 5-10 key words that could reflect content <strong>of</strong> the study mainly from<br />
Index Medicus.<br />
Text<br />
For most article types, the main text should be structured into the<br />
following sections: INTRODUCTION, MATERIALS AND METHODS,<br />
RESULTS and DISCUSSION, and should include in appropriate Figures<br />
and Tables. Data should be presented in the body text or in Figures and<br />
Tables, but not in both.<br />
Illustrations<br />
Figures should be numbered as 1, 2, 3 and so on, and mentioned clearly in<br />
the main text. Provide a brief title for each figure on a separate page. No<br />
detailed legend should be involved under the figures. This part should be<br />
added into the text where the figures are applicable. Digital images: black<br />
and white photographs should be scanned and saved in TIFF format at a<br />
resolution <strong>of</strong> 300 dpi; color images should be saved as CMYK (print files)<br />
but not as RGB (screen-viewing files). Place each photograph in a separate<br />
file. Print images: supply images <strong>of</strong> size no smaller than 126 mm × 85 mm<br />
printed on smooth surface paper; label the image by writing the Figure<br />
number and orientation using an arrow. Photomicrographs: indicate the<br />
original magnification and stain in the legend. Digital Drawings: supply files<br />
in EPS if created by freehand and illustrator, or TIFF from photoshops.<br />
EPS files must be accompanied by a version in native file format for editing<br />
purposes. Existing line drawings should be scanned at a resolution <strong>of</strong> 1200<br />
dpi and as close as possible to the size where they will appear when printed.<br />
Please use uniform legends for the same subjects. For example: Figure 1<br />
Pathological changes <strong>of</strong> atrophic gastritis after treatment. A: ...; B: ...; C: ...; D:<br />
...; E: ...; F: ...; G: ...<br />
Tables<br />
Three-line tables should be numbered as 1, 2, 3 and so on, and mentioned<br />
clearly in the main text. Provide a brief title for each table. No detailed<br />
legend should be included under the tables. This part should be added into<br />
the text where the tables are applicable. The information should complement<br />
but not duplicate that contained in the text. Use one horizontal line under the<br />
title, a second under the column heads, and a third below the Table, above<br />
any footnotes. Vertical and italic lines should be omitted.<br />
Notes in tables and illustrations<br />
Data that are not statistically significant should not be noted. a P
Instructions to authors 2647<br />
illustrations should be expressed as 1 F, 2 F, 3 F; or some other symbols with<br />
a superscript (Arabic numerals) in the upper left corner. In a multi-curve<br />
illustration, each curve should be labeled with ●, ○, ■, □, ▲, △, etc. in a<br />
certain sequence.<br />
Acknowledgments<br />
Brief acknowledgments <strong>of</strong> persons who have made genuine contributions<br />
to the manuscripts and who endorse the data and conclusions are included.<br />
Authors are responsible for obtaining written permission to use any<br />
copyrighted text and/or illustrations.<br />
REFERENCES<br />
Coding system<br />
The author should code the references according the citation order in text<br />
in Arabic numerals, put references codes in square brackets, superscript it<br />
at the end <strong>of</strong> citation content or the author name <strong>of</strong> the citation. For those<br />
citation content as the narrate part, the coding number and square brackets<br />
should be typeset normally. For example, Crohn’s disease (CD) is associated<br />
with increased intestinal permeability [1,2] . If references are directly cited in the<br />
text, they would be put together with the text, for example, from references<br />
[19,22-24 ], we know that...<br />
When the authors code the references, please ensure that the order in<br />
text is the same as in reference part and also insure the spelling accuracy <strong>of</strong><br />
the first author’s name. Do not code the same citation twice.<br />
PMID requirement<br />
PMID roots in the abstract serial number indexed by PubMed (http://www.<br />
ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed). The author should supply<br />
the PMID for journal citation. For those references that have not been<br />
indexed by PubMed, a printed copy <strong>of</strong> the first page <strong>of</strong> the full reference<br />
should be submitted.<br />
The accuracy <strong>of</strong> the information <strong>of</strong> the journal citations is very<br />
important. Through reference testing system, the authors and editor could<br />
check the authors name, title, journal title, publication date, volume number,<br />
start page, and end page. We will interlink all references with PubMed in<br />
ASP file so that the readers can read the abstract <strong>of</strong> the citations online<br />
immediately.<br />
Style for journal references<br />
Authors: the first author should be typed in bold-faced letter. The surname<br />
<strong>of</strong> all authors should be typed with the initial letter capitalized and followed<br />
by their name in abbreviation (For example, Lian-Sheng Ma is abbreviated<br />
as Ma LS, Bo-Rong Pan as Pan BR). Title <strong>of</strong> the cited article and italicized<br />
journal title (<strong>Journal</strong> title should be in its abbreviation form as shown in<br />
PubMed), publication date, volume number (in black), start page, and end<br />
page [PMID: 1<strong>18</strong>19634]<br />
Note: The author should test the references through reference testing<br />
system (http://www.wjgnet.com/cgi-bin/index.pl)<br />
Style for book references<br />
Authors: the first author should be typed in bold-faced letter. The surname<br />
<strong>of</strong> all authors should be typed with the initial letter capitalized and followed<br />
by their name in abbreviation (For example, Lian-Sheng Ma is abbreviated as<br />
Ma LS, Bo-Rong Pan as Pan BR) Book title. Publication number. Publication<br />
place: Publication press, Year: start page and end page.<br />
Format<br />
<strong>Journal</strong>s<br />
English journal article (list all authors and include the PMID where applicable)<br />
1 Grover VP, Dresner MA, Forton DM, Counsell S, Larkman DJ, Patel N,<br />
Thomas HC, Taylor-Robinson SD. Current and future applications <strong>of</strong><br />
magnetic resonance imaging and spectroscopy <strong>of</strong> the brain in hepatic<br />
encephalopathy. <strong>World</strong> J Gastroenterol 2006; 12: 2969-2978 [PMID:<br />
167<strong>18</strong>775]<br />
Chinese journal article (list all authors and include the PMID where applicable)<br />
2 Lin GZ, Wang XZ, Wang P, Lin J, Yang FD. Immunologic effect <strong>of</strong><br />
Jianpi Yishen decoction in treatment <strong>of</strong> Pixu-diarrhoea. Shijie Huaren<br />
Xiaohua Zazhi 1999; 7: 285-287<br />
In press<br />
3 Tian D, Araki H, Stahl E, Bergelson J, Kreitman M. Signature <strong>of</strong><br />
balancing selection in Arabidopsis. Proc Natl Acad Sci U S A 2006; In<br />
press<br />
Organization as author<br />
4 Diabetes Prevention Program Research Group. Hypertension,<br />
insulin, and proinsulin in participants with impaired glucose tolerance.<br />
Hypertension 2002; 40: 679-686 [ PMID: 12411462 ]<br />
Both personal authors and an organization as author<br />
5 Vallancien G, Emberton M, Harving N, van Moorselaar RJ; Alf-One<br />
Study Group. Sexual dysfunction in 1, 274 European men suffering<br />
from lower urinary tract symptoms. J Urol 2003; 169: 2257-2261 [PMID:<br />
12771764]<br />
No author given<br />
6 21st century heart solution may have a sting in the tail. BMJ 2002; 325:<br />
<strong>18</strong>4 [PMID: 12142303]<br />
Volume with supplement<br />
7 Geraud G, Spierings EL, Keywood C. Tolerability and safety <strong>of</strong><br />
frovatriptan with short- and long-term use for treatment <strong>of</strong> migraine<br />
and in comparison with sumatriptan. Headache 2002; 42 Suppl 2: S93-99<br />
[PMID: 12028325]<br />
Issue with no volume<br />
8 Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section<br />
analysis in revision total joint arthroplasty. Clin Orthop Relat Res 2002;<br />
(401): 230-238 [ PMID: 12151900 ]<br />
No volume or issue<br />
9 Outreach: bringing HIV-positive individuals into care. HRSA Careaction<br />
2002; 1-6 [PMID: 12154804 ]<br />
Books<br />
Personal author(s)<br />
10 Sherlock S, Dooley J. Diseases <strong>of</strong> the liver and billiary system. 9th ed.<br />
Oxford: Blackwell Sci Pub, 1993: 258-296<br />
Chapter in a book (list all authors)<br />
11 Lam SK. Academic investigator’s perspectives <strong>of</strong> medical treatment for<br />
peptic ulcer. In: Swabb EA, Azabo S. Ulcer disease: investigation and<br />
basis for therapy. New York: Marcel Dekker, 1991: 431-450<br />
Author(s) and editor(s)<br />
12 Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed.<br />
Wieczorek RR, editor. White Plains (NY): March <strong>of</strong> Dimes Education<br />
Services, 2001: 20-34<br />
Conference proceedings<br />
13 Harnden P, J<strong>of</strong>fe JK, Jones WG, editors. Germ cell tumours V.<br />
Proceedings <strong>of</strong> the 5th Germ Cell Tumour Conference; 2001 Sep<br />
13-15; Leeds, UK. New York: Springer, 2002: 30-56<br />
Conference paper<br />
14 Christensen S, Oppacher F. An analysis <strong>of</strong> Koza's computational effort<br />
statistic for genetic programming. In: Foster JA, Lutton E, Miller J,<br />
Ryan C, Tettamanzi AG, editors. Genetic programming. EuroGP<br />
2002: Proceedings <strong>of</strong> the 5th European Conference on Genetic<br />
Programming; 2002 Apr 3-5; Kinsdale, Ireland. Berlin: Springer, 2002:<br />
<strong>18</strong>2-191<br />
Electronic journal (list all authors)<br />
Morse SS. Factors in the emergence <strong>of</strong> infectious diseases. Emerg<br />
Infect Dis serial online, 1995-01-03, cited 1996-06-05; 1(1): 24 screens.<br />
Available from: URL: http//www.cdc.gov/ncidod/EID/eid.htm<br />
Patent (list all authors)<br />
16 Pagedas AC, inventor; Ancel Surgical R&D Inc., assignee. Flexible<br />
endoscopic grasping and cutting device and positioning tool assembly.<br />
United States patent US 20020103498. 2002 Aug 1<br />
Inappropriate references<br />
Authors should always cite references that are relevant to their article, and<br />
avoid any inappropriate references. Inappropriate references include those<br />
that are linked with a hyphen and the difference between the two numbers at<br />
two sides <strong>of</strong> the hyphen is more than 5. For example, [1-6], [2-14] and [1, 3,<br />
4-10, 22] are all considered as inappropriate references. Authors should not<br />
cite their own unrelated published articles.<br />
Statistical data<br />
Present as mean ± SD or mean ± SE.<br />
Statistical expression<br />
Express t test as t (in italics), F test as F (in italics), chi square test as χ 2 (in<br />
Greek), related coefficient as r (in italics), degree <strong>of</strong> freedom as γ (in Greek),<br />
sample number as n (in italics), and probability as P (in italics).<br />
Units<br />
Use SI units. For example: body mass, m (B) = 78 kg; blood pressure,<br />
p (B) = 16.2/12.3 kPa; incubation time, t (incubation) = 96 h, blood glucose<br />
concentration, c (glucose) 6.4 ± 2.1 mmol/L; blood CEA mass concentration,<br />
p (CEA) = 8.6 24.5 µg/L; CO2 volume fraction, 50 mL/L CO2 not 5% CO2;<br />
likewise for 40 g/L formaldehyde, not 10% formalin; and mass fraction,<br />
8 ng/g, etc. Arabic numerals such as 23, 243, 641 should be read 23 243 641.<br />
The format about how to accurately write common units and quantum<br />
is at: http://www.wjgnet.com/wjg/help/15.doc
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