Quantitative HBsAg: Not helpful to evaluate fibrosis in HBeAg-negative chronic hepatitis B patients Dimitri Loureiro, Abdellah Mansouri, Tarik Asselah Saudi Journal of Gastroenterology 2019 25(5):269-271

Endoscopic robotic suturing: The way forward Hung Leng Kaan, Khek Yu Ho Saudi Journal of Gastroenterology 2019 25(5):272-276 Traditionally, suturing is performed in open surgery using a needle holder and forceps. The aim is to achieve accurate approximation of both edges of the wound and to tie a secure knot. With the development of laparoscopic surgery, traditional suturing methods have been adapted to meet the constraints of rigid laparoscopic instruments with limited degrees of freedom. The subsequent introduction of three-dimensional robotic suturing has since made intracorporeal suturing easier to learn, primarily because of its intuitiveness and the additional degree of freedom of the robotic wrists. With the increasing popularity of therapeutic endoscopic procedures for early gastrointestinal cancers, devices allowing for endoscopic suturing have since been developed. Nevertheless, these devices remain challenging to use as they require double-channel endoscopes and do not have the extra degree of freedom of robotic wrists. The introduction of robotics to the field of endoscopic suturing has proven to be promising. This review describes the development and adaptation of basic suturing techniques to various platforms, such as laparoscopic, robotic and endoscopic.

Knowledge and attitudes of primary healthcare physicians toward the diagnosis and management of inflammatory bowel disease following an educational intervention: A comparative analysis Rwan Alharbi, Faizah Almahmudi, Yahya Makhdoom, Mahmoud Mosli Saudi Journal of Gastroenterology 2019 25(5):277-285 Background/Aims: Inflammatory bowel disease (IBD) is a chronic inflammatory condition that requires early diagnosis and proper management. Patients with early symptoms of IBD are typically evaluated first by primary healthcare (PHC) physicians, who in turn refer patients with suspected IBD to specialists. Therefore, we aimed to assess the knowledge and attitude of PHC physicians toward IBD. Materials and Methods: We conducted a comparative cross-sectional survey of PHC physicians practicing at the Ministry of Health PHC centers in Jeddah, KSA. Demographics and data on the knowledge and practices of physicians were collected through a predefined and tested questionnaire that included three domains (Eaden, Leong, and Sign/Symptom Awareness). A subgroup of the cohort was educated about IBD referral criteria (group A, n = 65) prior to study initiation and their responses were compared with those from the remaining group (group B, n = 135). Regression analysis was used to test associations with the significance threshold set at 5%. Results: A total of 211 PHC physicians were surveyed with a response rate of 95%. Female physicians comprised 66.5% of the cohort and the mean age was 32.26 ± 6.6 years. About 91% of physicians were Saudi nationals, and 75.5% were MBBS degree holders. The majority of the respondents (93%) reported seeing zero to five patients with IBD per month, and almost half of the physicians preferred to always refer patients to specialists (49.5%). Most of the respondents were uncomfortable (3.27 ± 1.4 to 4.35 ± 1.2) with initiating or managing specific medical therapies (maintenance therapy, therapy for acute flare, corticosteroids, immunomodulators, and biologics) for patients with IBD. With regard to knowledge, group A had higher scores in all three domains especially in the Sign/Symptom Awareness domain (mean score 6.17 ± 1.1 vs. 3.5 ± 1.01, P < 0.001). According to multivariate analyses, both groups' knowledge showed no significant relationship with any of the medical therapies, except for the Sign/Symptom Awareness domain which was shown to be significantly affecting the comfort of doctors in managing maintenance therapy among patients with IBD [odds ratio (OR) =1.61, P = 0.008]. Gender, nationality, and qualifications were found to have a significant influence on the comfort in initiating specific medical therapies. Group A was identified as a significant factor in predicting comfort with managing corticosteroids (OR = 8.25, P = 0.006) and immunomodulators (OR = 6.03, P = 0.02) on patients with IBD. Conclusion: The knowledge and comfort of PHC physicians with IBD medication prescription appears to be higher when education is provided. This observation is important, since PHC physicians are responsible for early identification and referral of patients suspected of having IBD, to specialists.

Quantitative HBsAg levels do not identify hepatic fibrosis in HBeAg-negative chronic hepatitis B patients Fatima A Ahmed, Maryam S Bajaifar, Mohammed A Ahmed, Abduljaleel Alalwan, Faraaz A Sanai, Khalid Albeladi, Abdulrahman A Aljumah, Faisal M Sanai Saudi Journal of Gastroenterology 2019 25(5):286-292 Background/Aims: Quantitative serum hepatitis B surface antigen (qHBsAg) has been evaluated in limited patient groups as a marker of histological fibrosis. The accurate identification of inactive chronic hepatitis B virus (HBV) carriers from those with active carriers is difficult because of wide and frequent HBV DNA fluctuations. We aimed to assess the utility of qHBsAg in distinguishing histologically significant fibrosis in untreated HBeAg-negative chronic HBV patients. Patients and Methods: qHBsAg levels were measured at baseline as single-point quantification and correlated with virologic and biochemical profiles of consecutive carriers (median, 29; range, 12-110 months). HBeAg-negative patients (n = 75) with HBV DNA <2000 (n = 5), 2000-20,000 (n = 16) and >20,000 IU/mL (n = 54) were included and all had liver biopsy. A qHBsAg cutoff point of 1000 IU/mL was assessed to demonstrate whether it better delineated patients with non-significant histology (F0-1, inflammatory grade A0-1). Results: Mean age of the patients was 39.4 ± 11.4 years and 58 (77.3%) were male. Patients with qHBsAg levels >1000 IU/mL were more likely to be males (84.5%, P = 0.006) or with elevated AST (68.4%, P = 0.0002) and ALT levels (72.4%, P < 0.0001), higher HBV DNA (log10 6.4 ± 1.4, P < 0.0001) and those with F2-4 fibrosis (48.3%, P = 0.028). Serum log10 qHBsAg were significantly lower in patients with HBV DNA <2000 (2.80 ± 1.47) and HBV DNA 2000-20,000 (2.71 ± 0.83) vs. >20,000 IU/mL (3.89 ± 0.61, P < 0.0001). Overall, qHBsAg were not different in patients with F0-1 (3.44 ± 0.91) and F2-4 fibrosis (3.74 ± 0.85, P = 0.161). Serum qHBsAg were higher in patients with significant (A2-3) inflammation (3.85 ± 0.72) compared to A0-1 (3.38 ± 0.95; P = 0.018). Serum qHBsAg demonstrated poor accuracy (AUROC, 0.61, P = 0.111) in identification of F2-4 fibrosis. Conclusion: Serum qHBsAg levels do not help differentiate between those with HBV DNA <2000 or 2000 – 20,000 IU/mL or distinguish patients with significant fibrosis. Moreover, more than half of the patients with non-significant fibrosis have a qHBsAg level greater than 1000 IU/mL.

COX-2/C-MET/KRAS status-based prognostic nomogram for colorectal cancer: A multicenter cohort study Jianhua Liu, Chengzhi Huang, Junjiang Wang, Ling Huang, Shaojie Chen Saudi Journal of Gastroenterology 2019 25(5):293-301 Background/Aim: To construct quantitative prognostic models for colorectal cancer (CRC) based on COX-2/C-MET/KRAS expression status in clinical practice. Patients and Methods: Clinical factors and COX-2/C-MET/KRAS expression status of 578 eligible patients from two Chinese hospitals were included. The patients were randomly allocated into training and validation datasets. We created several models using Cox proportional hazard models: SignatureC contained clinical factors, SignatureG contained COX-2/C-MET/KRAS expression status, and SignatureCG contained both. After comparing their accuracy, nomograms for progression-free survival (PFS) and overall survival (OS) were built for the best signatures, with their concordance index and calibration tested. Further, patients were subgrouped by the median of the best signatures, and survival differences between the subgroups were compared. Results: For PFS, among the three signatures, SignaturePFS-CG had the best area under the curve (AUC), with the 1-, 2- and 3-year AUCs being 0.70, 0.73 and 0.89 in the training dataset, respectively and 0.67, 0.73 and 0.87 in the validation dataset, respectively. For OS, the AUCs of SignatureOS-CG for 1-, 2- and 3-years were 0.63, 0.71 and 0.81 in the training dataset, respectively and 0.68, 0.71 and 0.76 in validation dataset, respectively. The nomograms based on SignaturePFS-CG and SignatureOS-CG had good calibrations. Subsequent stratification analysis demonstrated that the subgroups were significantly different for both PFS (training:P < 0.001; validation:P< 0.001) and OS (training:P < 0.001; validation:P < 0.001). Conclusions: Combining clinical factors and COX-2/C-MET/KRAS expression status, our models provided accurate prognostic information in CRC. They can be used to aid treatment decisions in clinical practice.

Bletilla striata polysaccharides ameliorates lipopolysaccharide-induced injury in intestinal epithelial cells Lei Luo, Yuqing Liu, Xin Cai, Yao Wang, Juan Xue, Juan Zhang, Fan Yang Saudi Journal of Gastroenterology 2019 25(5):302-308 Background/Aims: This study was carried out to investigate the effect of Bletilla striata polysaccharide (BSP) treating on lipopolysaccharide (LPS)-induced intestinal epithelial barrier disruption in rat intestinal epithelial cell (IEC) line. Materials and Methods: LPS was used to stimulate the IEC-18 cells (1 μg/ml), with or without different concentrations of BSP (25, 50 and 100 μg/ml) for 24 h. Transepithelial electrical resistance (TEER) was measured to detect the permeability of cells. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the cell supernatant were detected with the enzyme-linked immunosorbent assay (ELISA). Real-time polymerase chain reaction (PCR) was employed to detect the mRNA levels of zonulae occludens (ZO)-1 and occludin. Western blot and immunofluorescence analysis were used for analyzing the expression level and the distribution patterns of ZO-1 and occludin protein. Results: After treatment with BSP, the IL-6 and TNF-α levels in the cell supernatant were significantly decreased compared with the experiment group (P < 0.05 or 0.01). The permeability of IEC was decreased in BSP groups when compared with the experiment group (P < 0.05 or 0.01). In addition, compared with the experiment group, treatment with BSP up-regulated mRNA and protein expression levels of ZO-1 and occludin, and kept the ZO-1 and occludin protein intact in IEC-18 cells injured with LPS (P < 0.05 or 0.01). Conclusion: BSP has the capacity to protect IEC-18 cells from LPS-induced injury. The mechanisms may be associated with decreasing the inflammatory cytokine levels of IL-6 and TNF-α, and elevating the expression of ZO-1 and occludin, which might serve as a new protective agent for LPS-induced intestinal epithelial barrier disruption.

Where are we today with Helicobacter pylori infection among healthy children in Saudi Arabia? Abdulrahman A Al-Hussaini, Abdullah N Al Jurayyan, Salman M Bashir, Dayel Alshahrani Saudi Journal of Gastroenterology 2019 25(5):309-318 Background/Aims: The available studies on Helicobacter pylori (H. pylori) prevalence among healthy asymptomatic population across Saudi Arabia suffers from significant limitations. We conducted this large population-based study to estimate the H. pylori seropositivity rate among apparently healthy children in Saudi Arabia, using anti-H. pylori immunoglobulin A (IgA) and IgG serology tests, and to study the influence of H. pylori infection on growth. Materials and Methods: We conducted a cross-sectional study to screen apparently healthy school aged Saudi children (aged 6–15 years), attending primary and intermediate schools in Riyadh between 2014 and 2016, for H. pylori seropositivity by checking for the presence of anti-H. pylori IgG and IgA antibodies in serum specimens. Results: Out of 3551 serum specimens, 1413 cases tested seropositive for H. pylori organism (40%): 430 (12.2%) were both IgG and IgA positive, 212 (6%) and 771 (21.7%) cases showed isolated positivity for IgG or IgA, respectively. Male gender, older age, lower levels of socioeconomic status (SES), and family members >10 were significantly associated with H. pylori seropositivity. The proportion of participants with short stature was significantly more in the H. pylori seropositive group than the seronegative group (OR1.249, confidence interval [1.020–1.531], P= 0.033). There was no significant association between H. pylori seropositivity and gastrointestinal symptoms. Conclusion: The prevalence of H. pylori seropositivity among apparently healthy Saudi children (40%) is intermediate compared with that in developed and developing countries. The Saudi pediatric population shows a predominant IgA-type immunological response to H. pylori infection.

A randomized open label trial of tenofovir monotherapy versus tenofovir plus telbivudine in spontaneous reactivation of hepatitis B Ankur Jindal, Ashish Vyas, Manoj Sharma, Guresh Kumar, Shiv K Sarin Saudi Journal of Gastroenterology 2019 25(5):319-326 Background/Aim: Acute-on-chronic liver failure (ACLF-B) in spontaneous reactivation of chronic hepatitis B (SR-CHB) has high mortality. Tenofovir disoproxil fumarate (TDF) improves survival by ~40% in ACLF-B but is potentially nephrotoxic. Combining telbivudine (LDT) with TDF may negate this risk and could boost rapid viral clearance and improve clinical outcomes. Patients and Methods: Seventy consecutive patients with SR-CHB were randomized to TDF (300 mg/day, n = 35) or TDF plus LDT (600 mg/day; n = 35). In all, 25 had ACLF-B and none had option for liver transplantation. Primary endpoint was survival at 3 months. Secondary endpoints were survival at 3 months in ACLF-B, serial reduction in hepatitis B virus (HBV) DNA, hepatitis B surface antigen (HBsAg) loss and liver-related complications. Results: Overall baseline clinical and laboratory parameters in the two groups were comparable. Reduction in HBV DNA at weeks 2, 4 and 12 was independent of treatment groups and presence of ACLF-B (P < 0.01). All six patients with HBsAg loss at 12 weeks had lower HBV DNA at baseline and none had ACLF-B. Patients with no ACLF-B had more rapid decline in bilirubin and alanine aminotraminase at week 2 compared with ACLF-B. Patients on TDF plus LDT showed significant improvement in AKI on follow-up (five of six patients) compared with TDF monotherapy (none of six patients) and had less reduction in estimated glomerular filtration rate at week 12. Eight of 10 patients with liver-related deaths received TDF monotherapy (P = 0.02). New-onset septic shock, TDF monotherapy, e-antibody positivity, and higher baseline model for end-stage liver disease score were predictors of mortality in ACLF-B. None had treatment-related severe adverse effects. Conclusion: Addition of LDT to tenofovir is safe and may be renoprotective in spontaneous reactivation of hepatitis B. Combination therapy improves survival in ACLF-B despite comparable HBV DNA suppression to tenofovir monotherapy.

Determination of the optimal volume of ascitic fluid for the precise diagnosis of malignant ascites Feifei Zhang, Zhenning Feng, Yichi Zhang, Zishuai Liu, Xiaoli Sun, Shizhu Jin Saudi Journal of Gastroenterology 2019 25(5):327-332 Background/Aims: The aim of this study was to determine the optimal volume of peritoneal effusion required to diagnose malignant ascites. Patients and Methods: The authors recruited 123 patients with shifting dullness and obtained 123 peritoneocentesis fluid samples. The samples were divided into seven aliquots of 10, 50, 100, 150, 200, 250, and 300 mL for cytopathological examination. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated for each aliquot. Results: The sensitivity for the diagnosis of malignant ascites gradually increased as the sample volume increased and reached a constant value at a volume of 200 mL. The sensitivity and NPV for the 10-, 100-, and 150-mL volumes were significantly different from those for the 200-mL sample. However, the sensitivity and NPV for the 250- and 300-mL volumes were not significantly different. The sensitivity for the diagnosis of malignant ascites is closely related to the volume of peritoneal fluid that is extracted by peritoneocentesis. Conclusion: We suggest a volume of 200 mL as the optimal minimum volume to confirm malignant ascites in patients with shifting dullness.