Ureteral metal stents: a tale or a tool?

There are four types of ureteral metal stents: self expandable, balloon expandable, covered, and thermoexpandable shape-memory. Insertion of metal stents requires expertise with transurethral and percutaneous techniques. The stricture is traversed with the aid of a guidewire via a percutaneous nephrostomy, and the stenotic segment is dilated using a high-pressure balloon catheter. The stent is then inserted over the guidewire, such that the upper end bypasses the obstruction by at least 3 to 4 cm, while the lower end extends intravesically for 0.5 to 1 cm from the ureteral orifice. If necessary, two or more stents are placed in sequence, overlapping by at least 2 to 3 cm. Metal stents were initially used for the relief of end-stage malignant disease, and their role in the treatment of benign ureteral strictures is still undefined. Patients often complain of abdominal discomfort and mild pain after stent insertion, which soon resolve spontaneously. Hematuria usually stops after a few days and does not necessitate any treatment. Mild urothelial hyperplasia in the stent lumen is common but usually regresses after 4 to 6 weeks. Many authors suggest the use of a double-pigtail catheter for the first 4 to 6 weeks to avoid narrowing of the ureteral lumen. The influence of stents on ureteral peristalsis is a major but poorly documented issue. Encrustation is a significant problem that needs to be addressed. The characteristics of both the patient and the stent influence its likelihood. Migration of coated metal stents was seen in 81% of patients at our center. Virtual endoscopy has recently been introduced as a tool for the follow-up of patients with stented ureters. Further design development is necessary to obtain the ideal ureteral metal stent. In a recent study in female pigs, paclitaxel-eluting metal stents engendered less inflammation and hyperplasia of the surrounding tissues.     

Flory syndrome or lymphomonocytic/low-neutrophil oligoarthritis: a diagnosis or a prognosis?

OBJECTIVE: To individualize a new clinical entity of chronic arthritis and/or a factor indicating good prognosis of chronic arthritis. METHODS: We retrospectively studied 12 cases of monoarthritis or oligoarthritis that met none of the criteria sets for known diseases, even after more than 10 years of follow-up. RESULTS: Features in these 12 patients included recurrent effusions of inflammatory joint fluid consistently showing a predominance of lymphocytes and monocytes, long periods of remission separating the flares, absence of clinical or radiological joint lesions despite prolonged follow-up (10-40 years), an excellent response to joint aspiration and intraarticular glucocorticoid injection, unresponsiveness to second-line drugs, and young age at onset. Males and females were equally affected. Absolute lymphocyte/monocyte counts in joint fluid were similar in the 12 study patients and in 59 patients with rheumatoid arthritis, whereas absolute and differential neutrophil counts were significantly lower in the study patients. CONCLUSION: The above-described features and excellent functional outcome suggest that this clinical pattern may deserve to be viewed as a separate entity. We suggest the name "idiopathic lymphomonocytic arthritis" or, since a low-neutrophil count in joint fluid was also a conspicuous finding, "Flory syndrome", Flory being the name of the first patient in our series.     

State of hepatocyte transplantation: a risk or a chance?

Over the past few years, hepatocyte transplantation has been considered as an alternative method for orthotopic liver transplantation for the treatment of various liver diseases. Beside curative approach for genetic metabolic deficiencies (familial hypercholesterolemia, hemophilia, etc.), it could be a useful tool for bridging the waiting period until an appropriate donor organ is obtained. In preclinical animal studies, hepatocytes injected intraperitoneally, intraportally or into the spleen settle down in the diseased liver. This enables genetic modification to correct inborn metabolic deficiencies and improves survival in acute liver failure. In 1992, the first clinical transplantation of isolated hepatocytes in 10 patients was performed. In 1998, Fox and coworkers described the successful transplantation of allogeneic liver cells in a child with Crigler-Najjar syndrome. Accomplished studies of Strom et al. resp. Bilir et al. of the same year proved the effectiveness of liver cell transplantation for transient treatment of acute liver failure. Prerequisite of this cell-based therapeutic strategy is a sufficient amount of highly differentiated hepatocytes, hence, a well established in-vitro cell-culture technique is necessary to yield a reproducible number of proliferating hepatocytes and to preserve the physiological cell function. This review discusses the different experimental approaches regarding the cultivation of human hepatocytes and also the use of alternative cell sources (like animal hepatocytes, immortalized cells of human origin, progenitor cells from fetal human liver/liver stem cells) for hepatocyte transplantation.     

Big Data: Progress or a Big Headache?

Large administrative database, or “big data” research studies can include an immense number of patients. Strengths of research based on big data include generalizability resulting from diverse patients, diverse providers, and diverse clinical settings. Limitations of research based on large administrative databases may include indeterminate quality and obscure purpose of data entry, lack of information regarding confounding variables, and suboptimal clinical outcome measures. Thus, research conclusions based on big data must be scrutinized in a discerning and critical manner.     

Oncoplastic multidisciplinary meetings: a necessity or luxury?

Although there is scant evidence to support multidisciplinary meetings in any cancer specialty, they are now regarded as best practice. We believe the oncoplastic multidisciplinary meeting plays a similarly important role, consolidating oncoplastic multidisciplinary working and allowing transparent decision making, standardisation of care and recording of results. This may drive oncoplastic surgery to an evidence-based position from which oncoplastic excellence can be achieved.