As an aging society, China has an increasing number of elderly patients (≥80 years) . Given the characteristics of pancreaticobiliary diseases in elderly patients, therapeutic endoscopic retrograde cholangiopancreatography (TERCP) has become the main approach for these patients. When TERCP is performed in elderly patients with pancreaticobiliary diseases, a more detailed strategy is needed in addition to active preoperative evaluation and emergency treatment of medical and surgical complications. TERCP provides a good therapy for elderly patients with pancreaticobiliary diseases, and it is simple, safe, and convenient.

The differential diagnosis of pancreatic head mass has been clinical difficulties. Endoscopic ultrasonography is now recognized as one of the sensitive and effective methods for the diagnosis of pancreatic diseases. This paper discusses the diagnostic performance of endoscopic ultrasonography for various common types of pancreatic head mass, as well as the radiological features of this disease, reviews the diagnostic value and safety of endoscopic ultrasonography-guided fine needle aspiration for pancreatic head mass, and briefly introduces the advances in the application of additional new techniques of endoscopic ultrasonography for this disease. Finally, it is pointed out that endoscopic ultrasonography has a high diagnostic value for pancreatic head mass.

Objective To evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with cirrhosis. Methods A retrospective analysis was performed on the clinical data of 347 patients who were admitted to Beijing You'an Hospital and received ERCP from January 2010 to November 2013. Patients were divided into three groups: patients without liver diseases (n = 258) , patients with chronic hepatitis (n = 40) , and patients with cirrhosis (n = 49) . One-way ANOVA or Kruskal-Wallis H test was performed to compare changes in alanine aminotransferase (ALT) , aspartate transaminase (AST) , albumin (Alb) , total bilirubin (TBil) , white blood cells (WBC) , percentage of neutrophils (NEUT) , and serum amylase between the three groups of patients after ERCP. The incidence rates of complications, including hyperamylasemia, acute pancreatitis, infection, hemorrhage, and perforation, and distribution of disease spectrum diagnosis the changes in liver function and blood amylase after ERCP were analyzed compared between the three groups using chi-square test. Results Patients with cirrhosis had significantly lower levels of serum Alb, ALT, and AST than patients in the other two groups before ERCP (H = 3. 68, P = 0. 028; H = 14. 03, P = 0. 001, and H = 8. 00, P = 0. 018, respectively) . After ERCP, the TBil level was significantly higher in the cirrhosis group than in the other two groups (H = 6. 69, P = 0. 035) . Compared with the serum levels of AST and TBil before ERCP, 44. 9% (22 /49) of patients with cirrhosis had higher levels of AST and TBil 3 days after ERCP, the incidence of which was the highest among all three groups. The percentage of NEUT 1 day after ERCP in patients with cirrhosis was 73. 9% ± 12. 7%, which was similar to that in patients without liver diseases (74. 8% ± 11. 0%) and higher than that in patients with chronic hepatitis; the difference between the three groups was statistically significant (H = 7. 31, P = 0. 026) . Although no significant difference in the percentage of patients who had > 80%NEUT 3 days after ERCP was observed between the three groups, the percentage was the highest in the group of patients with cirrhosis (18. 4%, 9 /258) . The incidence rate of hyperamylasemia 24 hours after ERCP 24 h was significantly higher in patients with cirrhosis (53. 1%) than in patients without liver diseases (31. 8%) or with chronic hepatitis (40. 0%) (χ2= 8. 48, P = 0. 014) . The overall complication rates in patients with cirrhosis (18. 4%) was significantly higher than that in patients without liver diseases (8. 1%) or with chronic hepatitis (7. 5%) (χ2= 26. 73, P < 0. 001) . Conclusion ERCP is a safe and effective therapeutic intervention and well tolerated by patients with cirrhosis. Hyperamylasemia should be closely monitored after ERCP.

Objective To compare the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy (ET) in reducing recurrent variceal hemorrhage in patients with cirrhosis. Methods Data from randomized controlled trials (RCTs) ranging from January 1st, 1970 to January 1st, 2014 that compared the use of TIPS with ET for the prophylaxis of recurrent variceal bleeding in cirrhosis patients were retrieved from databases including Pub Med, Ovid, Science Direct, Embase, Wanfang Data, and CNKI. The quality of eligible RCTs was assessed, and a meta-analysis was performed on the incidence of variceal rebleeding (VRB) and post-treatment encephalopathy, deaths due to rebleeding and other causes, and hospitalization days using the Cochrane Collaboration's Rev Man 5. 2 software. Heterogeneity test and sensitivity analysis were performed, and publication biases were evaluated. Results Thirteen RCTs involving 475 cases of TIPS and480 cases of ET were recruited in our study following the inclusion criteria. The meta-analysis showed that compared with the ET group, the TIPS group had a lower incidence of VRB [relative risk (RR) = 0. 48, 95% confidence interval (CI) : 0. 39-0. 58, P < 0. 001 ], reduced deaths due to rebleeding (RR = 0. 37, 95% CI: 0. 20-0. 69, P = 0. 001) , but a higher incidence of post-treatment encephalopathy (RR = 1. 84, 95% CI: 1. 47-2. 30, P < 0. 001) . No significant differences were found in overall mortality and hospitalization days between the two groups (RR = 1. 09, 95% CI: 0. 88-1. 35, P = 0. 44; weighted mean difference =-0. 44, 95% CI:-3. 25-2. 38, P= 0. 76) . Conclusions Compared with ET, TIPS increases the risk of hepatic encephalopathy. However, in some special cases, it remains the first choice of treatment to prevent variceal rebleeding.

Objective To examine the efficacy of endoscopic variceal ligation (EVL) as a secondary prophylaxis for cirrhotic patients associated with esophageal varices, and to identify the risk factors for postoperative rebleeding. Methods A retrospective analysis was performed on the clinical data of cirrhotic patients with esophageal variceal bleeding (EVB) in the Peking University First Hospital from 2000 to2012. Patients were divided into ligation and control (conservative treatment) groups and their prognosis was followed up. According to the outcome, the ligation group was further divided into rebleeding and non-rebleeding groups for comparative analysis of clinical data. Continuous data were compared between groups using the independent samples t-test, and data were converted before t-test when necessary.Ranked data were analyzed using the Mann-Whitney U test, and categorical data were compared between groups using the χ2test. Results A total of 139 patients were enrolled, 119 assigned to the ligation group and 20 to the control group. At the end of the follow-up period (1 to 24 months) , the rebleeding, early rebleeding, and mortality rates significantly differed between the ligation and control groups (P<0. 05) , i. e., 41. 2%, 8. 4% and 7. 6% in the ligation group versus 70. 0%, 20. 0% and 40. 0% in the control group, respectively. In the ligation group, comparative analysis showed that the history of hepatic encephalopathy, ascites, Child-Pugh score, and platelet count significantly differed between the rebleeding and non-rebleeding groups (P < 0. 05) . Conclusion As a secondary prophylaxis therapy, EVL can effectively improve the prognosis of cirrhosis associated with EVB. The deterioration of liver function may indicate a higher risk of rebleeding. Therefore, it is necessary to improve patients basic conditions during EVL therapy.

Objective To compare the clinical efficacy of endoscopic variceal ligation versus pericardial devascularization in the treatment of portal hypertension. Methods The clinical data of 101 cirrhotic patients with gastroesophageal varices and variceal hemorrhage from January2010 to January 2012 were analyzed. Fifty-three patients received endoscopic variceal ligation, and forty-eight patients received pericardial devascularization. Postoperative changes in liver function and hypersplenism were compared between the two groups. The rate of rehaemorrhagia and incidence of postoperative complications after surgery were compared as well. Continuous data were expressed as mean ± SD, and categorical data were expressed as number of cases or percentage. Comparison of continuous data between the two groups was made by independent-samples t test, and comparison of categorical data was made by chi-square test. Results After surgery, the variceal ligation group showed no significant changes in liver reserve function, while the albumin level was significantly decreased in the pericardial devascularization group (t =2. 512, P < 0. 05) . There were no significant changes in the counts of white blood cells and platelets in the endoscopic variceal ligation group after surgery (P > 0. 05) , but significant increases in the counts of white blood cells and platelets were detected in the pericardial devascularization group (P < 0. 05) . The rates of postoperative haemorrhage in the two groups were: 3 months, 7. 5% vs 6. 2% (χ2= 0. 066, P > 0. 05) , 6 months, 7. 5% vs 8. 3% (χ2= 0. 021, P > 0. 05) , and 1 year, 9. 4% vs 8. 3% (χ2= 0. 038, P > 0. 05) . The incidence rates of postoperative complications in the two groups were 24. 5% and 50%, respectively (χ2= 7. 040, P < 0. 05) . Conclusion Compared with pericardial devascularization, endoscopic variceal ligation causes fewer microlesions, preserves liver function, and leads to a lower incidence of postoperative complications. However, if hypersplenism is observed in the cirrhotic patients with gastroesophageal varices and variceal hemorrhage, pericardial devascularization can be used to control the hypersplenism and prevent esophageal hemorrhage.

Objective To evaluate the clinical effects of laparoscopic hepatectomy (LH) versus open hepatectomy (OH) in treating liver metastasis of colon cancer. Methods Relevant literature published up to October 2014 was retrieved from databases including Pub Med, Medline, Embase, and Cochrane Library. Extended search was done with reference to the retrieved articles. The quality of selected studies was assessed by the Jadad scale. Meta-analysis was performed using the Cochrane Review Manager software (Version 5. 3. 4) . Results A total of 10 studies involving 786 patients met the inclusion criteria. Meta-analysis showed no significant differences in duration of operation, perioperative mortality, and 5-year overall survival rate between patients undergoing LH and OH (95% CI:-61. 98-23. 68, 0. 08-4. 05, and 0. 60-1. 58, respectively, P > 0. 05 for all) , but there were significant differences in intraoperative blood loss, incidence of postoperative complications, and length of hospital stay (95% CI:-323. 17- (-113. 00) , 0. 38-0. 77, and-5. 01- (-2. 04) , respectively, P < 0. 05) . Conclusion The results of this meta-analysis suggest that LH has comparable efficacy and safety to OH in treating liver metastasis of colon cancer and LH has its own advantage.

Objective To analyze the clinical effects of several different approaches to laparoscopic cholecystectomy. Methods A total of400 patients who received cholecystectomy in our hospital from January 2013 to September 2014 were divided into four groups according to the approaches to laparoscopy (n = 100 per group) : single-port laparoscopic cholecystectomy, two-trocar laparoscopic cholecystectomy, three-trocar laparoscopic cholecystectomy, and four-trocar laparoscopic cholecystectomy. All clinical data were systematically analyzed on six indicators: blood loss during surgery, operation time, time to ambulation after surgery, time to taking meal after surgery, length of hospital stay after surgery, and the degree of pain at 6 h after surgery (rating of pain scale) . The clinical effects of the different approaches were compared between the four groups. Results Significant differences were observed in the following indicators: the degree of pain at 6 h after surgery between the groups of single-port and two-trocar laparoscopic cholecystectomy [ (2. 7 ± 0. 4 vs 1. 9 ± 0. 8) , P = 0. 036]; operation time between the groups of single-port and three-trocar laparoscopic cholecystectomy [ (55. 6 ± 23. 5) min vs (36. 0 ± 24. 3) min, P =0. 028]; length of hospital stay between the groups of single-port and three-trocar laparoscopic cholecystectomy [ (3. 0 ± 2. 3) d vs (5. 2± 3. 3) d, P = 0. 042]. All other indicators showed no significant differences between groups (P > 0. 05) . Statistical analysis of the six indicators indicated that all four approaches did not significantly influence the incidence of surgical complications (P > 0. 05) . Conclusion All the four approaches to laparoscopic cholecystectomy are safe and feasible, but the operation techniques should be standardized, anatomical knowledge should be mastered, and any changes in the surgical situation should be strictly monitored. Before the surgery, the patients' wishes and their physical conditions should be considered to choose the appropriate surgical approach and improve the surgical safety.

Objective To investigate the safety and superiority of fast track surgery (FTS) in elderly patients during the perioperative period of laparoscopic cholecystectomy (LC) . Methods The clinical data of 124 elderly patients who underwent LC at the Department of General Surgery in our institution between January 2010 and March 2014 were assessed, with 62 cases assigned to FTS group and 62 cases to conventional method group. Anal exhaust time, feeding time, off-bed activity time, and length of hospital stay were compared between the two groups, and postoperative results and adverse reactions were recorded. Continuous data were analyzed using the independent-samples t test, and categorical data were compared using the chi-square test. Results Compared with the control method group, patients in the FTS group showed earlier postoperative anal exhaust, feeding, and off-bed activity, a shorter length of hospital stay, and a lower incidence of postoperative cardiovascular and cerebrovascular complications (P < 0. 05) . Conclusion FTS is an effective approach to accelerate rehabilitation in elderly patients after LC.

Objective To evaluate the causes, diagnostic and therapeutic principles, and prevention of the perforation related to endoscopic retrograde cholangiopancreatography (ERCP) . Methods All patients who developed perforation after ERCP in the Central Hospital of Shanghai Jiading District from January 2009 to December 2013 were recruited. The causes, types, and diagnosis and treatment of perforation were analyzed retrospectively. Results ERCP was done in 459 cases during the 4 years, and 6 (1. 3%) of them developed perforation.The causes of perforation were as follows: endoscope insertion (3 cases) , catheterization or sphincterotomy (2 cases) , and guide wire or Dormia basket (1 case) . Two cases received conservative management successfully and were discharged; four cases underwent surgical treatment, and one of them died. Conclusion Patients with ERCP-related perforation can achieve ideal prognosis through individualized treatment based on the causes and types of perforation. Careful and cautious operation, especially for the elderly or the patients with a history of upper abdominal operation, will reduce the incidence of ERCP-related perforation.

Objective To compare the clinical efficacy and adverse effects of metformin versus vitamin E in the treatment of nonalcoholic fatty liver disease (NAFLD) . Methods Randomized controlled trials (RCTs) of NAFLD treatment with metformin and vitamin E, which were published before April 10, 2014, were retrieved from international and domestic biomedical databases including the Pub Med, EMbase, Cochrane Library, Web of Science, CNKI, WANFANG, VIP, and CBM. Clinical trials that met the inclusion criteria were chosen for meta-analysis. Results Four RCTs were included, of which three were published in English and one in Chinese. Meta-analysis data showed that metformin had a significantly higher effective rate than vitamin E in terms of serum alanine aminotransferase (ALT) alternation post oral treatment (P < 0. 0001) . There were no significant differences in body mass index (BMI) and serum aspartate aminotransferase (AST) , fasting blood glucose (FBG) , and triglyceride (TG) levels post oral treatment (P = 0. 30, 0. 39, 0. 82, and 0. 74, respectively) . Liver biopsy showed that after metformin treatment, the alterations in fatty degeneration and lobular inflammation scores, as well as balloon-like changes, were less than those post vitamin E treatment. Regarding clinical safety, metformin effectively reduced serum ALT and gamma-glutamyl transferase levels without causing hepatocyte damage (P = 0. 008 and 0. 01, respectively) . Only one RCT mentioned the occurrence of mild diarrhea and abdominal pain or discomfort in the metformin group, but there was no significant difference from the vitamin group. Conclusion Among NAFLD patients, metformin reduces serum ALT levels more significantly than vitamin E, while the latter has its advantage in improving the results of liver biopsy. However, these two drugs have no significant differences in reducing BMI and AST, FBG, and TG levels. This study included limited numbers of original references and patients, and it might involve selection and implementation biases. RCTs of higher quality are expected to provide more effective evidence for assessing the clinical efficacy and adverse reactions of metformin versus vitamin E.

Objective To investigate the effect of salvianolic acid B on hepatocyte apoptosis in rats with nonalcoholic steatohepatitis (NASH) and the efficacy of salvianolic acid B in the treatment of NASH. Methods Sixty clean male SD rats were randomly divided into control group, NASH model group, and salvianolic acid B treatment group, with 20 rats in each group. The control group was fed with normal diet, while the other two groups with high-fat diet for 12 continuous weeks to establish a NASH model. From week 13, rats in the treatment group were gavaged with 1 mg / ml salvianolic acid B (20 ml / kg b. w. daily) ; while the model group with distilled water (20 ml / kg b. w daily) . After 12 weeks of treatment, the rats were sacrificed; blood and hepatic tissues were sampled, liver index (liver weight / body weight) calculated, serum levels of alanine aminotransferase (ALT) , aspartate aminotransferase (AST) , triglycerides (TG) , and total cholesterol (TC) measured, and the pathologic changes in hepatic tissues observed. The protein expression of caspase-3 and cytochrome C (Cyt C) in hepatic tissues was measured by immunohistochemical methods. The mRNA expression of p53, Bax, and Bcl-2 in hepatic tissues was measured by RT-PCR. Results Compared with the normal group, the model group showed higher liver index and serum levels of ALT, AST, TG, and TC and more obvious inflammation of hepatic tissues; the protein expression of Cyt C and caspase-3 was significantly increased (P < 0. 01 for both) ; the mRNA expression of Bcl-2 was significantly reduced (P < 0. 01) , while that of Bax and p53 was significantly increased (P < 0. 01 for both) . Compared with the model group, the treatment group showed alleviated inflammation and reduced liver index and serum levels of ALT, AST, TG, and TC; the protein expression of Cyt C and caspase-3 was significantly reduced (P < 0. 01 for both) ; Bcl-2 mRNA expression was significantly increased (P < 0. 05) , p53 mRNA expression significantly reduced (P < 0. 05) , and Bax mRNA expression also significantly reduced (P < 0. 01) . Conclusion Salvianolic acid B can inhibit hepatocyte apoptosis and treat NASH by regulating the mRNA expression of Bcl-2, p53, and Bax and reducing the protein expression of Cyt C and caspase-3.

Objective To evaluate the therapeutic efficacy and toxicity of oxaliplatin (OXA) -based systemic chemotherapy in patients with advanced hepatocellular carcinoma (HCC) . Methods Thirty patients with advanced HCC admitted to our hospital from June 2009 to June 2013 were randomly divided into Cape OX group (15 patients, treated with OXA and capecitabine or CAP) and FOLFOX group (15 patients, treated with OXA and calcium folinate or CF, followed by fluorouracil or 5-FU) . The therapeutic effects were evaluated after two cycles of treatment using the Response Evaluation Criteria in Solid Tumors (RECIST 1. 1) . Assessment criteria included overall response rate (OR) , time to tumor progression (TTP) , and overall survival (OS) analyzed by Kaplan-Meier survival curves, as well as the toxicity profile of the combination chemotherapy. Comparison of OR was made by chi-square test; assessment of tumor response and toxicity profile was performed by Mann-Whitney U test; OS and TTP were analyzed by log-rank test. Results In the Cape OX group, the OR was13. 3%, and the mean OS and TTP were 10. 4 months and 5. 0 months, respectively. In the FOLFOX group, the OR was 6. 7%, and the mean OS and TTP were 9. 0 months and 4. 7 months, respectively. The differences between the two groups had no statistical significance in all three parameters (P = 0. 543, 0. 606, and 0. 769, respectively) . Compared with the FOLFOX group, the Cape OX group had significantly lower toxicity rates in gastrointestinal tract and myelosuppression (P = 0. 006 and 0. 002, respectively) . Conclusions The OXA-based systemic chemotherapy shows anti-tumor effects for advanced HCC, and there is no significant difference in efficacy between the two regimens. Decisions regarding the choice of specific treatment should be based on the patients' clinical conditions.