Objective:To evaluate the safety and efficacy of indwelling cutting with guidewire in treatment of difficult pancreatic duct stricture.Methods:A retrospective study was performed on the data of patients with chronic pancreatitis, who failed to implant pancreatic duct stent by endoscopic retrograde cholangiopancreatography (ERCP) and whose narrow pancreatic duct only allowed the guidewire to pass through, in Nanjing Drum Tower Hospital from November 2017 to April 2019. The dilatation effect of guidewire indwelling on difficult pancreatic duct stenosis was studied. The duration of guidewire indwelling, the success rate of stent re-implantation, the level of postoperative amylase, recent complications, and follow-up results were analyzed.Results:A total of five patients received indwelling guidewire after failure of dilation of pancreatic duct stenosis during ERCP. After 2.4 days of mean indwelling time, all patients received re-ERCP. The narrow pancreatic duct was successfully expanded and the stent was placed. In terms of complications, only one patient suffered from acute pancreatitis after the first ERCP, and was improved after medical treatment.Conclusion:Guidewire indwelling is a new simple, safe, and effective method for dilatation of pancreatic duct stenosis, and has important clinical value in the management of difficult intubation of pancreatic duct in chronic pancreatitis.

Objective:To compare the safety and effectiveness of endoscopic full-thickness resection (EFR) and cap-assisted endoscopic full-thickness resection (EFR-C) in the treatment of small gastric stromal tumors (≤1.5 cm) in the elderly (≥60 years old).Methods:Data of elderly patients with small gastric stromal tumors who received EFR (41 cases) or EFR-C (25 cases) at Nanjing Drum Tower Hospital from May 2012 to August 2020 were analyzed retrospectively. The clinicopathological characteristics, the procedures, intraoperative and postoperative complications, postoperative efficacy and economic benefits were compared between the two groups.Results:The R0 resection rates of the EFR group and the EFR-C group were 95.1% (39/41) and 100% (25/25), respectively. The operation time [45.0 (32.5, 66.5) min VS 30.0 (20.0, 42.5) min, U=259.500, P=0.001] and resection time [30.0 (20.0, 50.5) min VS 9.0 (6.5, 16.5) min, U=127.000, P<0.001] of the EFR group were significantly longer than those of the EFR-C group. The rate of hot clamp use in the EFR group was higher than that in the EFR-C group [75.6% (31/41) VS 12.0% (3/25), χ ２=25.159, P<0.001]. The postoperative white blood cell count [8.3 (6.6,10.4)×10 9/L VS 6.3 (5.0,7.7) ×10 9/L, U=271.000, P=0.001] and postoperative neutrophil percentage (77.6%±8.8% VS 73.0%±6.8%, t=2.256, P=0.027) in the EFR group were higher than those in the EFR-C group. The postoperative antibiotic day in the EFR group was longer than that in the EFR-C group (2.8±2.0 days VS 1.0±2.0 days, t=3.625, P=0.001). The hospitalization costs in the EFR group were significantly higher than those in the EFR-C group (20 595.0±3 653.3 yuan VS 13 209.0±4 458.9 yuan, t=7.323, P<0.001). There was no recurrence or metastasis during the follow-up period. Conclusion:EFR and EFR-C are safe and effective for the treatment of small gastric stromal tumors in the elderly. Compared with EFR, EFR-C needs shorter operation time and lower medical costs, yields less postoperative inflammation, and is more suitable for the treatment of small gastric stromal tumors in the elderly.

Objective:To compare the safety and efficacy of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for the treatment of biliary obstruction at different locations.Methods:From January 2016 to June 2021 data of 82 patients with obstructive jaundice treated with EUS-HGS in Nanjing Drum Tower Hospital were reviewed in this retrospective cohort study. According to the location of biliary obstruction,patients were divided into hilar biliary obstruction group ( n=30) and distal biliary obstruction group ( n=52). Univariate and multivariate logistic regression analyses were conducted adjusting covariates to compare the technical success rate, the clinical success rate, the adverse reaction incidence, hospital stay and cost of the two groups. Results:The technical success rates were 93.3% (28/30) and 94.2% (49/52) in the hilar biliary obstruction group and the distal biliary obstruction group with no significant difference between the two groups ( P=0.870, OR=1.17, 95% CI: 0.18-7.41). The clinical success rates were 83.3% (25/30) and 88.5% (46/52) in the hilar biliary obstruction group and the distal biliary obstruction group with no significant difference between the two groups ( P=0.514, OR=1.53, 95% CI: 0.43-5.53). The incidence of adverse events in hilar biliary obstruction group was 10.0% (3/30), including cholangitis 3.3% (1/30), biliary fistula 6.7% (2/30), biliary peritonitis 6.7% (2/30). The incidence of adverse events in patients with distal biliary obstruction was 17.3% (9/52), including cholangitis 9.6% (5/52), biliary fistula 7.7% (4/52) and biliary peritonitis 5.8% (3/52). There was no significant difference in the incidence of adverse events between the two groups ( P>0.05). Conclusion:There is no significant difference in safety or efficacy of EUS-HGS for hilar biliary obstruction and distal biliary obstruction.

Objective:To evaluate the long-term efficacy of endoscopic transluminal drainage(ETD) for acute pancreatitis complicated with walled-off necrosis (WON) or pancreatic pseudocyst (PPC).Methods:A total of 79 patients who were diagnosed as having WON or PPC by abdominal CT or ultrasound and treated with ETD in Nanjing Drum Tower Hospital were enrolled. Past medical records and follow-up by phone call after discharge were analyzed for long-term outcomes including endocrine and exocrine functions and long-term quality of life.Results:A total of 50 patients were enrolled, including 31 patients with infected WON/PPC and 19 patients with uninfected WON/PPC. Seventeen patients (54.84%) in the infected WON/PPC group and 11 patients (57.89%) in the uninfected WON/PPC group lost 5% or more of their weight. There were no significant differences in the proportion of cases of weight loss of 5% or more ( P=0.833), or the weight loss between the two groups (12.59±8.89 kg VS 10.91±2.47 kg, P=0.522). Only one patient in the infected WON/PPC group had chronic abdominal pain. There was no significant difference in the Izbicki score between the two groups (23.79±6.74 VS 22.03±3.21, P=0.295). None of the patients developed steatorrhea after discharge. Five patients (16.67%, 5/30) in the infected WON/PPC group and 6 patients (40.00%, 6/15) in the uninfected WON/PPC group developed endocrine insufficiency with no significant difference ( P=0.140). Greater risk of secondary diabetes resulted from higher low-density lipoprotein cholesterol ( HR=1.9, 95% CI: 1.0-3.4, P=0.044)and triglycerides ( HR=1.2, 95% CI: 1.0-1.3, P =0.029). Conclusion:ETD is safe and effective for WON and PPC. But there is possibility that patients develop secondary diabetes. Additionally, greater risk of secondary diabetes results from higher low-density lipoprotein cholesterol and triglycerides.

Objective:To analyze the clinicopathological characteristics of differentiated early cardia cancer and to evaluate the short-term and long-term efficacy of endoscopic submucosal dissection (ESD).Methods:A total of 329 patients (331 lesions) who underwent ESD at Nanjing Drum Tower Hospital from October 2014 to December 2019 and were pathologically confirmed as differentiated early cardia cancer were included in the study and followed up. The endoscopic and pathological data of patients were reviewed to analyze the clinicopathological characteristics of differentiated early cardia cancer. The short-term (including en bloc resection rate, curative resection rate and incidence of short-term complications) and long-term efficacy (including incidence of metachronous cancer, recurrence and distant metastasis, and overall survival rate) of ESD was evaluated.Results:The ratio of male to female in 329 patients with differentiated early cardia cancer was 4∶1, and their age was 65.69±8.02 years. Tumor diameter of ≤2.0 cm accounted for 65.9% (218/331). Most lesions were located on the posterior wall (50.5%, 167/331), followed by the minor curve (36.3%, 120/331). The endoscopic morphology of 0-Ⅱc type accounted for 49.5% (164/331). There were 69.8% (231/331) lesions confined to the mucosal layer. The en bloc resection rate was 100.0% (329/329), and the curative resection rate was 83.3% (274/329). Short-term complications occurred in 28 patients (8.5%). With a median follow-up time of 39 months, 11 patients (3.3%) developed metachronous cancer, 2 (0.6%) developed distant metastasis, and no recurrence occurred. Seven patients died, and the overall survival rate during the follow-up period was 97.9% (322/329). The survival rate of patients with curative resection and additional surgery was 100.0% (3/3), while that without additional surgery was 99.3% (269/271). The survival rate of patients with non-curative resection and additional surgery was 96.0% (24/25), and that without additional surgery was 86.7% (26/30).Conclusion:Most differentiated early cardia cancers are well-differentiated adenocarcinomas, with less than 2 cm in diameter at the time of diagnosis with a low rate of ulcer and vascular invasion. ESD is safe and effective for the treatment of differentiated early cardia cancer with a high rate of curative resection, fewer intraoperative and postoperative complications, low incidences of metachronous cancer, distant metastasis and recurrence, and a high overall survival rate. However, additional surgical treatment is recommended for patients with non-curative resection.

Objective:To compare the safety and efficacy of laparoscopy and laparotomy for 5-10 cm intermediate-risk gastric stromal tumor, and to evaluate whether there was evident benefits of postoperative adjuvant treatment with imatinib.Methods:A retrospective study was conducted on 72 patients with moderate risk gastric stromal tumors (5-10 cm in diameter) who received operation in Nanjing Drum Tower Hospital from January 2010 to July 2020. There were 28 cases in the laparoscopy group and 44 cases in the laparotomy group. The clinical features, pathological data, perioperative results and hospitalization costs were compared between the two groups. The survival rates of postoperative adjuvant therapy with or without imatinib were analyzed and compared.Results:There was no significant difference in clinicopathological features between the two groups ( P>0.05). The incidences of postoperative complications in the laparoscopy group and the laparotomy group were 32.1% (9/28) and 52.3% (23/44) respectively, showing no significant difference ( P=0.094). Compared with the laparotomy group, both the hospital stay (12.5±3.2 days VS 15.0±3.5 days, P=0.004) and the median postoperative hospital stay (7.5 days VS 9.0 days, P=0.006) in the laparoscopy group were significantly shorter, and the first exhaust time was significantly shorter ( P=0.003). During the median follow-up period of 58 months (13-129 months), there was no tumor-related death. Two cases died of breast cancer and heart disease in the laparotomy group, and 1 case died irrelevant to gastric stromal tumor in the laparoscopy group. Of the 72 patients, 40 received postoperative imatinib adjuvant therapy, 22 cases (50.0%) in the laparotomy group and 18 cases (64.3%) in the laparoscopy group, with no significant difference in the proportion ( χ2=1.414, P=0.234). There was significant difference in the overall survival rate between the group treated with imatinib and the group without imatinib ( P=0.015). Conclusion:Laparoscopic resection is safe and effective for intermediate-risk gastric stromal tumor of 5-10 cm. Taking imatinib adjuvant treatment does not increase overall survival rate of patients with intermediate-risk gastric stromal tumors (5-10 cm), and there is no tumor-related death, recurrence or metastasis for those who did not accept imatinib adjuvant treatment after R0 resection.

Objective:To compare the efficacy and safety of endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR) for intraluminal gastric stromal tumors.Methods:Data of 441 patients diagnosed as having gastric stromal tumors in Nanjing Drum Tower Hospital from June 2009 to June 2020 were retrospectively analyzed. A total of 241 patients underwent ESE (ESE group) and 200 EFR (EFR group). Epidemiological data (gender, age and body mass index), tumor size, procedure related parameters, complications, hospital stay, cost and follow-up were compared between the two groups.Results:There were no significant differences between the two groups in gender, age, body mass index, tumor size, National Institutes of Health risk grade, complete resection rate, or block resection rate ( P>0.05). Compared with the EFR group, the ESE group required less titanium clips to close defects in the stomach wall [6.0 (4.0, 6.0) VS 6.0 (5.0, 8.0), U=18 424.0. P<0.001], shorter time of first postoperative fluid intake [2.0 (1.0, 2.0) days VS 2.0 (2.0, 3.0) days, U=17 420.0, P<0.001] and hospital stay [6.0 (5.0, 8.0) days VS 7.0 (6.0, 9.0) days, U=18 906.0, P<0.001], and lower total cost [18.9 (16.4, 21.4) thousand yuan VS 20.9 (18.1, 23.8) thousand yuan, U=17 956.0, P<0.001]. Moreover, the total incidence of complications of the ESE group was lower than that of the EFR group [5.8% (14/241) VS 11.5% (23/200), χ2=4.605, P=0.032]. Patients were followed up with the median period of 45.0 months. The disease recurrence rate was 0.45% (2/441), and there were no disease-related deaths. Conclusion:The efficacy is comparable between ESE and EFR for treating intraluminal gastric stromal tumors, but ESE shows a lower incidence of complications, and requires a shorter hospital stay and lower cost.

Objective:To study the safety and efficacy of endoscopic submucosal dissection (ESD) for early gastric cardia cancer (EGCC) in elderly patients.Methods:A retrospective analysis was performed on data of 499 EGCC patients who underwent ESD from January 2011 to June 2018 in Nanjing Drum Tower Hospital. The patients were divided into two groups by age, the young/middle-aged group (<65 years old) and the elderly group (≥65 years old). The baseline data, lesion features, postoperative complications, short-term efficacy and long-term efficacy of the two groups were compared.Results:The elderly group included 272 patients (283 lesions) and the young/middle-aged group included 227 patients (229 lesions). Except that there were significant differences in the age ( P<0.001) and body mass index ( P=0.002) between the elderly group and the young/middle-aged group, there were no significant differences in the baseline data or pathological features between the two groups. The rate of curative resection in the elderly group was 77.0%, lower than that in the young/middle-aged group (84.3%, P=0.045). No significant differences were found in en bloc resection rate (100.0% VS 99.6%, P=1.000), complete resection rate (94.7% VS 93.9%, P=0.705), postoperative complications incidence (6.4% VS 5.7%, P=0.747), operation time (64.02±39.24 min VS 66.16±44.62 min, P=0.566) or hospitalization time (6.76±2.06 d VS 6.47±1.74 d, P=0.092]. After the median follow-up of 47.9 months, 13.4% patients in the elderly group received additional surgery, which was slightly lower than that in the young/middle-aged group ( P=0.891). There were no significant differences in postoperative recurrence, lymph node metastasis, distant metastasis, overall mortality and disease-related mortality between the two groups. The survival analysis showed that five-year overall survival rates were 94.41% and 96.34% in the elderly group and the young/middle-aged group respectively ( P=0.156), and five-year disease-specific survival rate were 99.18% and 99.03% in the two groups respectively ( P=0.858). Conclusion:ESD is safe and effective for EGCC in elderly patients with satisfactory short-term and long-term efficacy.

Objective:To investigate the risk factors for the relapse of autoimmune pancreatitis (AIP) after steroid therapy.Methods:Clinical data of 72 AIP patients treated with steroids in Nanjing Drum Tower Hospital from January 2012 to December 2023 were collected retrospectively. AIP patients were divided into relapse group ( n=25) and non-relapse group ( n=47) based on the presence or absence of their relapse after steroid therapy. Patients' age of onset, gender, history of diabetes mellitus, first clinical manifestations, serum IgG4 and CA19-9 level, imaging features and other organ involvements were recorded. Oral prednisone was used at an initial dose of 0.6 mg·kg -1·d -1, gradually reduced to 5-10 mg/d and then maintained at a low dose. The follow-up period started from steroid initiation to the last follow-up or relapse. The presence of maintenance steroid treatment, time interval between onset and steroid initiation, the presence of significant IgG4 decrease and the presence of persistently enlarged pancreas after therapy were recorded. The cumulative relapse rate curve after steroid therapy was drawn by Kaplan-Meier method. Univariate and multivariate analyses were performed by Cox proportional hazard regression model. The receiver operator characteristic curves (ROC) were plotted and the area under the curve (AUC) was calculated. The Log-Rank test was used to analyze the differences on the relapse between different groups. The subgroup forest plot was drawn to assess the effect of risk factors on the relapse of AIP in different subgroups. Results:The 72 patients with AIP had a median follow-up of 42 (12-127) months. 34.7% (25/72) of patients relapsed after steroid therapy during the follow-up period. The percentages of patients whose first clinical manifestation was abdominal distension or acute pancreatitis, whose interval between onset and steroid initiation was more than 1 year and whose pancreases were persistently enlarged after steroid therapy in the relapse group were higher than those in the non-relapse group, and the differences were all statistically significant (all P value <0.05). The 1-, 3- and 5-year cumulative relapse rate after steroid therapy was 20.8%, 34.1% and 37.8%, respectively. Univariate analysis found that the first clinical manifestations of abdominal distension or acute pancreatitis, interval between onset and steroid initiation more than 1 year, and persistently enlarged pancreas after steroid therapy were all significantly associated with relapse (all P value <0.05). Multivariate analysis found that interval between onset and steroid initiation more than 1 year and persistently enlarged pancreas after steroid therapy were independent risk factors for relapse of AIP [hazard ratio ( HR)=3.606 and 6.515, 95% confidence interval (95% CI) 1.362-9.854 and 2.088-20.326]. Kaplan-Meier survival curves showed that the relapse rate after steroid therapy was higher in AIP patients whose interval between onset and steroid initiation was more than 1 year than in those whose interval was less than 1 year (55.6% versus 27.8%), and the relapse rate in AIP patients with persistently enlarged pancreas after steroid therapy was higher than that in those without it (77.8% versus 28.6%), and the differences were both statistically significant (both P<0.05). Subgroup forest plot showed that persistently enlarged pancreas after steroid therapy was an independent risk factor for relapse of AIP regardless of the presence of a diabetes mellitus history, the first manifestation of abdominal pain, the diffuse or focal type in pancreatic imaging, and the presence of dilated pancreatic duct or not (all P value <0.05). Conclusions:Time interval between onset and steroid initiation more than 1 year and persistently enlarged pancreas after steroid therapy were independent risk factors for the relapse of AIP after steroid therapy.

Objective To assess the efficacy of endoscopic ultrasound-guided enteroenterostomy(EUS-EE)in the management of malignant bowel obstruction(MBO).Methods Retrospective analysis was conducted on clinical data from 14 patients who underwent EUS-EE for MBO from June 2022 to December 2023.A modified intestinal preparation protocol was employed prior to the procedure,and the resolution of symptoms,improvement in nutritional status,and occurrence of complications were statistically analyzed post-EUS-EE.Results EUS-EE was successfully performed in all 14 cases.The Colorectal obstruction scoring system(CrOSS)was used to evaluate preoperative and postoperative symptom relief and alleviation of bowel obstruction.One week after the procedure,CrOSS scores increased from 1 to 2 before surgery to 2～4.The patient-generated subjective global assessment(PG-SGA)score for malignancy patients demonstrated a mean score of(9.64±3.13)one week after surgery among the study cohort of 14 patients.This score showed a significant decrease compared to their preoperative PG-SGA score(12.36±3.22),with a statistical difference(t=2.26,P=0.032).Postoperatively,five patients experienced elevated body temperature,three had pneumoperitoneum,and two developed short bowel syndrome;However,these complications were effectively managed through symptomatic treatment resulting in recovery or relief thereof.At one-year follow-up,the median survival time was recorded as 81(41,500)d with a one-year survival rate at 64.29％.Conclusion EUS-EE offers advantages such as high remission rates for symptoms,minimal trauma,and low reintervention rates.For patients with poor baseline conditions or limited life expectancy,EUS-EE can alleviate physical discomfort symptoms,improve quality of life,and prolong survival period.