Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial

Background

Since its introduction in 2010, per oral endoscopic myotomy (POEM) has offered an alternative to laparoscopic Heller myotomy for the treatment of achalasia. A gastric myotomy length of 3 cm has been recommended; however, it can be difficult to ensure that adequate submucosal dissection has been performed during the procedure. Commonly accepted endoscopic markers of the gastric side can be inaccurate, particularly in patients with prior endoscopic treatments, such as balloon dilation or Botox injection of the lower esophageal sphincter. We hypothesized that the use of a second endoscope would result in a more complete gastric myotomy.

Methods

One hundred consecutive achalasia patients were randomized into single- and double-scope POEM groups. In the treatment group, a second endoscope was used to obtain a retroflexed view of the gastric cardia, while the dissecting scope transilluminated from the end of the submucosal tunnel. Prospectively collected data were analyzed, including myotomy lengths, procedure times, adverse events, and clinical outcomes.

Results

POEM was completed with high rates of technical (98–100 %) and clinical success (93–97 %) in both groups, with a low rate of serious adverse events (2 %). The second endoscope resulted in a 17 min increase in procedure time (94 vs. 77 min), myotomy extension in 34 % of cases, and an increase in the average gastric myotomy length from 2.6 to 3.2 cm (p = 0.01).

Conclusion

A second endoscope is useful for ensuring a complete gastric myotomy during POEM. With minimal increase in procedure time and no increase in morbidity, it may be particularly useful in cases of sigmoid esophagus or otherwise altered anatomy that makes identification of the gastroesophageal junction difficult.

     

Strong cytoplasmic expression of NF-κB/p65 correlates with a good prognosis in patients with triple-negative breast cancer

Purpose

Recent studies have indicated that constitutive NF-κB activity could be involved in the proliferation of triple-negative breast cancer.

Methods

The NF-κB/p65 expression and the effects of a NF-κB inhibitor, (?)-DHMEQ, were examined in triple-negative MDA-MB-231 breast cancer cells. Women with triple-negative breast cancer treated with neoadjuvant chemotherapy between 2002 and 2012 were retrospectively analyzed for their expression of NF-κB/p65, Bcl2 and Ki67 by immunohistochemistry in pre- and post-treatment specimens. The factors predicting the response to neoadjuvant chemotherapy and the prognosis were analyzed.

Results

NF-κB/p65 was predominantly expressed in the cytoplasm of MDA-MB-231 cells. Of 34 triple-negative breast cancer patients, positive staining for NF-κB/p65 expression was detected in the nuclei of a few cells in seven tumors before neoadjuvant chemotherapy, while the expression of NF-κB/p65 in the cytoplasm was detected in almost all tumor cells of 33 tumors. The expression levels of NF-κB/p65 were not associated with the response to neoadjuvant chemotherapy, although the cytoplasmic NF-κB/p65 staining intensity was significantly decreased in the post-treatment tumor samples compared with the pretreatment samples. All patients whose tumors showed strong cytoplasmic NF-κB/p65 expression before neoadjuvant chemotherapy are currently disease free.

Conclusion

Our results suggest that strong cytoplasmic NF-κB/p65 expression could be a prognostic marker for patients with triple-negative breast cancer.

     

Allogenic blood transfusion is an independent risk factor for infective complications after less invasive gastrointestinal surgery

BACKGROUND: The present study aimed to clarify the predisposing factors for postoperative infectious complications after less invasive surgery. METHODS: A total 150 surgical patients were placed in either group H (operative blood loss > or = 500 mL) or group L (<500 mL). The patients' background factors and postoperative inflammatory responses were assessed. RESULTS: The operating time was an independent risk factor for infectious complication in group H. In contrast, allogenic blood transfusion was the only significant risk factor for infection in group L. In the patients who received blood transfusion, exaggerated postoperative interleukin-6 response was found in group H, whereas an increased consumption of interleukin-6 soluble receptor with resultant induction of immunosuppressive acidic protein (IAP) were found in group L. CONCLUSIONS: Perioperative blood transfusion may predominantly contribute to increased susceptibility to infection after less invasive surgery through increased affinity of interleukin-6 soluble receptor and enhanced IAP response.     

Expression and localization of connective tissue growth factor (CTGF/Hcs24/CCN2) in osteoarthritic cartilage

OBJECTIVE: The investigation of the expression and localization of connective tissue growth factor/hypertrophic chondrocyte-specific gene product 24/CCN family member 2 (CTGF/Hcs24/CCN2) in normal and osteoarthritic (OA) cartilage, and quantification of CTGF/Hcs24-positive cells. METHODS: Cartilage samples of patients (n=20) with late stage OA were obtained at total joint replacement surgery. Morphologically normal cartilage was harvested for comparison purposes from the femoral heads of 6 other patients with femoral neck fracture. Paraffin-embedded sections were stained by Safranin O. The severity of the OA lesions was divided into four stages (normal, early, moderate, and severe). The localization of protein and mRNA for CTGF/Hcs24 was investigated by immunohistochemistry and in situ hybridization, respectively. The population of CTGF/Hcs24-positive chondrocytes in OA cartilage and chondro-osteophyte was quantified by counting the number of the cells under light microscopy. RESULTS: Signals for CTGF/Hcs24 were detected in a small percentage of chondrocytes throughout the layers of normal cartilage. In early stage OA cartilage, the CTGF/Hcs24-positive chondrocytes were localized mainly in the superficial layer. In moderate to severe OA cartilage, intense staining for CTGF/Hcs24 was observed in proliferating chondrocytes forming cell clusters next to the cartilage surface. In chondro-osteophyte, strong signals were found in the chondrocytes of the proliferative and hypertrophic zones. CONCLUSION: CTGF/Hcs24 expression was detected in both normal and OA chondrocytes of human samples. The results of the current study suggested that expression of CTGF/Hcs24 was concomitant with development of OA lesions and chondrocyte differentiation in chondro-osteophyte.     

Active chemotherapy with gemcitabine, carboplatin and docetaxel for three patients with MVAC-resistant liver metastasis of urothelial carcinoma

We report three cases with methotrexate-vinblastin-adriamycin-cisplatin (MVAC) resistant multiple liver metastases of urothelial carcinoma that responded to combination chemotherapy consisting of gemcitabine plus carboplatin (GC) with additional docetaxel (GCD) as salvage chemotherapy. Case 1: A 55-year-old man underwent left nephroureterectomy for ureteral cancer (TCC, G3, pT3pN1M0). Three courses of GC followed by three courses of GCD were given via intra-hepatic arterial infusion for multiple liver metastases, which appeared after adjuvant high-dose MVAC therapy. Complete response was obtained and maintained for 11 months. Case 2: A 46-year-old man underwent radical cystectomy for locally advanced bladder cancer (TCC G3 + adenocarcinoma. pT3pN0M0). Two courses of GC followed by 2 courses of GCD systemic therapies were performed for multiple liver metastases, which appeared after adjuvant high-dose MVAC therapy. Partial response was obtained and maintained for six months. Case 3: A 66-year-old man received three courses of MVAC for multiple metastases of the bladder cancer (TCC, G3, > pT2), which resulted in disease progression. Eight courses of GC followed by six courses of GCD were administrated via intra-hepatic arterial infusion. Partial response was obtained and maintained for 12 months. Although the response duration was still short, GC and GCD may be promising salvage chemotherapeutic regimens for the patients with MVAC-resistant liver metastases of urothelial carcinoma.     

Intradural extramedullary hemangioblastoma differentiated by MR images in the cervical spine: a case report and review of the literature

We report a rare case of hemangioblastoma existing in the intradural extramedullary location diagnosed by magnetic resonance imaging (MRI) examination alone. A 46-year-old man gradually developed numbness in his lower extremities. MR images revealed a tumor shadow located posterior to the spinal cord at C5-C7. Small signal void shadows were continuously observed from C1 to C5 in the region cranial to the tumor, indicating the presence of enlarged vessels. Under microscopic observation, the tumor with accompanying vessels was resected totally via hemilaminectomy. The postoperative course was uneventful, and MR images obtained 4 months after the operative procedure demonstrated total removal of the tumor and the abnormal vessels. In this case, recognizing the abnormally enlarged vessels outside the tumor mass preoperatively led us to the correct diagnosis on MR images.     

Midterm results of coronary artery bypass graft surgery with internal thoracic artery under low free-flow conditions

Background

We use the left internal thoracic artery (LITA) even when flow is very low. In this study, we investigated midterm outcome of coronary artery bypass graft surgery with low free-flow LITA.

Methods

One hundred patients undergoing coronary artery bypass graft surgery using LITA with a free flow of less than 20 mL/min were reviewed. The mean follow-up duration was 47.4 months, ranging from 1 to 65 months. Graft angiography was performed postoperatively. The diameter of the LITA was assessed angiographically. Cumulative graft patency, cardiac-related event-free rate, and actuarial survival rate were calculated by the Kaplan-Meier method.

Results

An early postoperative Doppler study showed that the diastolic-to-systolic ratio in the LITA was 1.76 ± 0.33. A 1-month postoperative angiography revealed LITA string sign in 2 patients. One had a percutaneous coronary intervention, whereas string sign was not detected in the second patient, and LITA patency showed a marked improvement in 1-year postoperative angiogram. One month postoperatively the LITA diameter was 1.6 ± 0.4 mm, and significantly enlarged in the second angiogram (1.9 ± 0.4 mm, p = 0.0003). There was a significant correlation between the diameter of the LITA and the left anterior descending coronary artery (r = 0.889, p = 0.0001). The cumulative graft patency rate at 1 and 4 years was 99.0% and 94.3%, respectively. The cardiac-related event-free rate at 1 and 5 years was 97.0% and 93.3%, respectively. The actuarial survival rate at 5 years was 97.1%.

Conclusions

Even with a very low LITA free flow, graft function improves with LITA growth, if there was no mechanical damage that impedes recovery.     

Pneumoperitoneum without perforation of the gastrointestinal tract

Pneumoperitoneum (PP) is usually the result of perforation of the gastrointestinal (GI) tract with associated peritonitis. However, other rare causes, including spontaneous PP incidental to intrathoracic, intra-abdominal, gynecologic, and miscellaneous other origins not associated with a perforated GI tract have been described in the literature. Six cases of PP without any perforated GI tract are reported. Three patients with generalized peritonitis underwent exploratory laparotomy or laparoscopy when clinical examinations suggested an acute abdomen. At surgical procedure, perforated pyometra, perforated liver abscess and a ruptured necrotic lesion of a liver metastasis were documented in these patients, respectively. We also saw 3 PP patients not associated with peritonitis. Two patients with PP caused by pneumatosis cystoides intestinalis were encountered, 1 was managed conservatively and the other received diagnostic laparoscopy. A patient in whom pneumomediastinum and pneumoretroperitoneum were accompanied by PP caused by an alveolar rupture based on decreased pulmonary compliance due to malnutrition was managed conservatively. The history of the patient and knowledge of the less frequent causes of PP can possibly contribute towards refraining from exploratory laparotomy in the absence of peritonitis.     

Diffusion tensor imaging in patients with major cerebral artery occlusive disease

Diffusion tensor (DT) imaging provides quantitative information about the magnitude and the directionality (anisotropy) of water diffusion in vivo and can detect pathologic changes in brain ischemia. This study tried to detect ischemic brain damage using DT imaging in patients with symptomatic chronic major cerebral artery occlusive disease. DT imaging was performed using a 3.0 Tesla magnetic resonance (MR) scanner in 50 patients with unilateral internal carotid artery or middle cerebral artery stenosis or occlusion, who had no obvious infarct lesions on conventional MR imaging. Thirty-three patients underwent DT imaging before and after vascular reconstruction surgery. Fractional anisotropy (FA) was calculated in the middle cerebral artery territory. Preoperative FA values in the ipsilateral side were significantly lower than those in the contralateral side. After surgery, the FA value was significantly increased. DT imaging may indicate ischemic brain damage, not visualized by conventional MR imaging, in patients with major cerebral artery occlusive disease.     

Augmented central cholinergic mechanisms in spontaneously hypertensive rats. Involvement of deranged noradrenergic mechanisms in the brain

Intracerebroventricular (ICV) injections of carbachol produced biphasic blood pressure responses consisting of initial vasodepression of short duration followed by a sustained pressor phase, which were accompanied by corresponding changes in sympathetic nerve activity in normotensive outbred-Wistar rats (NT) under urethane-anesthesia. In both normotensive Kyoto Wistar rats (WKY) and spontaneously hypertensive rats (SHR), on the other hand, carbachol elicited purely pressor responses, and accompanying sympathetic nerve activity was little affected. The magnitude of the pressor responses was larger in SHR than in WKY or NT rats. Spinal sectioning did not affect the magnitude of the pressor responses. Vasopressor responses to intravenous injections of arginine-vasopressin were not significantly different between WKY and SHR. These results indicate that carbachol injected intracerebroventricularly produces vasopressor effects mainly by releasing pituitary hormones, probably vasopressin, and that augmented pressor responses in SHR may be due to excessive release of vasopressin. When central noradrenergic neurons had been destroyed with ICV injections of 6-hydroxydopamine in both NT and WKY rats, carbachol-induced vasopressor responses were markedly augmented and resulted in responses similar to those of SHR. These findings indicate that central noradrenergic vasodepressive neurons are deficient and that the augmented vasopressor responses to carbachol resulted from deranged central noradrenergic mechanisms in SHR.