Arterial stiffness: Is it ready for prime time?

Recent interest in arterial stiffness as a possible new biomarker of cardiovascular (CV) disease has emerged. Arterial stiffness of the large, elastic conduit arteries is considered a risk marker of vascular aging; it leads to widened pulse pressure (PP) and the development of isolated systolic hypertension in the middle-aged and elderly population. However, increased PP is not always a good surrogate for arterial stiffening because of the frequent discrepancy between peripheral brachial and central aortic PP values caused by varying wave reflection activity. Therefore, noninvasive, easily performed methods for more direct measurement of arterial stiffness, such as pulse wave velocity (PWV) and pulse wave analysis (PWA) have been developed for clinical use. This article asks the question: How useful are PWV and PWA, when compared with traditional measurement of blood pressure components, as biomarkers of CV disease?     

Stereotactic body radiation therapy (SBRT) in pancreatic cancer: is it ready for prime time?

Pancreatic cancer is a devastating disease with few effective treatment modalities. Stereotactic body radiation therapy is a novel technique that takes advantage of the technologic advancements in image guidance and radiation dose delivery to direct ablative doses to tumors with acceptable toxicity that was not previously achievable with conventional techniques. Recent literature contains reports of stereotactic body radiation therapy in patients with locally advanced pancreatic tumors. This paper presents a summary of the current data and highlights the limitations and the promise. Further clinical study in the form of multi-institutional trials is warranted to establish the role of stereotactic body radiation therapy as a comparable noninvasive alternative to surgery.     

Minimally invasive surgical techniques for pancreatic cancer: ready for prime time?

Background

Minimally invasive surgical techniques for pancreatic cancer are being applied with increasing frequency. With support of the literature, the location of the tumor within the pancreas is the factor which determines if these techniques can be safely used routinely by pancreatic surgeons.

Methods

Literature supporting minimally invasive techniques for all types of resections for pancreatic cancer was reviewed.

Results

Multiple meta-analysis regarding laparoscopic distal pancreatectomy all support the routine use of laparoscopy for these lesions. There are several case series describing the safety and efficacious use of laparoscopy in pancreaticoduodenectomy, and results have been promising in these highly specialized centers.

Conclusions

The location of the tumor within the pancreas remains the most critical factor in the use of laparoscopy as the standard of care. Lesions in the body and tail, which are readily resected with a distal or subtotal pancreatectomy should be performed laparoscopically unless there is a clear reason why not to do so. Lesions in the head of the pancreas have been shown to be removed safely and effectively with laparoscopy. However, the technical skills necessary and the ability to teach these to trainees are the limiting factors to widespread use. Further series are necessary to assess if the laparoscopic approach to pancreaticoduodenectomy will play a similar role as the one it plays in the surgical treatment for distal lesions.     

Endoscopic ultrasound-guided anastomosis: Is it ready for prime time?

Significant advancements in endoscopic ultrasound (EUS)-guided drainage procedures and EUS-guided anastomosis have recently been described. The described procedures include EUS-guided drainage of pancreatic fluid collections, biliary drainage, pancreatic duct drainage, gallbladder drainage, and gastroenterostomy. These procedures have been made possible with novel devices that can reduce the difficulties of the procedures and potentially reducing the risk of adverse events. The procedures are also becoming standardized, which is essential for dissemination of the techniques. Furthermore, results from randomized studies are becoming available showing definite benefits associated with these procedures. In this paper, we will provide a review on EUS-guided anastomotic procedures.     

Endothelial function: ready for prime time?

The strategic location of the endothelium allows it to detect changes in hemodynamic forces and blood-borne signals, and to respond by releasing a number of autocrine and paracrine substances. The balanced release of these bioactive factors facilitates vascular homeostasis. If disrupted, endothelial cell dysfunction ensues. This predisposes the vessel wall to vasoconstriction, leukocyte adherence, platelet activation, thrombosis, vascular inflammation and atherosclerosis. Given the central role of the endothelium in the development and progression of atherosclerosis, endothelial function testing may serve as a useful biomarker of atherosclerotic disease. The present review highlights the current modalities used in assessing endothelial function, explores how endothelial function may serve as a biomarker for atherosclerosis, comments on the prognostic relevance of endothelial function and describes its use in the clinical setting.     

CT for assessing ventricular remodeling: Is it ready for prime time?

Reliable assessment of left ventricular size and systolic function has important prognostic and therapeutic implications for patients with heart disease. CT technology is advancing rapidly and can be used for noninvasive assessment of the coronary anatomy. Without additional radiation or contrast, the already acquired image data set can be used for analysis of left ventricular size, mass, and systolic function. In comparison with other noninvasive modalities, multidetector CT has superior spatial resolution but temporal resolution has suffered. Recent advances, including multisegment reconstruction and dual-source scanning, have improved the temporal resolution substantially. MRI is the current gold standard for assessing the left ventricle. Many small comparative studies suggest that CT has good agreement with MRI and that it could potentially replace MRI in some patients, especially those with internal cardiac devices. The use of CT to assess ventricular remodeling is limited by the use of contrast and radiation, but its widespread availability, ease of use, and improved temporal resolution suggest that multidetector CT will have expansive use in the future.     

Endoscopic ultrasound guided gallbladder drainage——is it ready for prime time?

Management of acute cholecystitis includes initial stabilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography(ERCP). Although, these conservative measures are effective, they can cause significant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound(EUS) guided gallbladder drainage is a novel method of gallbladder drainage first described in 2007~([1]). Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneous cholecystostomy and trans-papillary gallbladder drainage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.     

Computed tomographic colonography: ready for prime time?

Computed tomographic (CT) colonography is a noninvasive method to evaluate the colon and has received considerable attention in the last decade as a colon-imaging tool. The technique has also been proposed as a potential primary colon cancer-screening method in the United States. The accuracy of the technique for the detection of large lesions seems to be high, perhaps in the range of colonoscopy. Overall, the field is rapidly evolving. Available data suggest that CT colonography, although a viable colon cancer screening modality in the United States, is not ready for widespread implementation, largely because of the lack of standards for training and reading and the limited number of skilled readers.