Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses

Background

Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.

Methods

From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.

Results

In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1–78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤10 versus >10 mm (68 vs. 64 %; p = 0.479).

Conclusion

CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.     

Drug use in women with anorexia and bulimia nervosa

Forty-two inpatient women with bulimia nervosa and 29 women with anorexia nervosa were surveyed regarding eating behavior, patterns of licit and illicit substance use, and relation between drug use and appetite. Substantial use of licit substances such as laxatives, diuretics, and emetics were reported in women with bulimia nervosa. In addition, alcohol and cigarette use were significantly more common in women with bulimia nervosa than anorexia nervosa. The majority of bulimic subjects reported that smoking decreased appetite, alcohol increased appetite, and laxatives had no effect on appetite. Analysis of temporal patterns of drug intake suggested that binging and purging as well as alcohol, cigarette, and laxative use were considerably more prevalent in the evening hours. We suggest that the high rates of drug use in women with bulimia nervosa may be related to effects of food deprivation associated with the disorder.     

Intracutaneous botulinum toxin A versus ablative therapy of Hailey-Hailey disease - a case report

BACKGROUND: Hailey-Hailey disease is an autosomal-dominant blistering disease affecting the intertriginous skin. Dermabrasion and ablative laser treatment are known to be curative. Sweating is a common aggravating factor. Botulinum toxin A (BTXA) has been shown to inhibit sudoriferic nerves. OBJECTIVE: To evaluate whether a treatment with BTXA induces remissions and can compete with ablative therapy. To compare dermabrasion with erbium:YAG laser therapy. METHOD: Case report with side-by-side comparison. We used intracutaneous BTXA on both sides of the submammary region. Four days later a limited area of 25 cm 2 on each side was treated with either dermabrasion or erbium:YAG laser. The follow-up was 12 months. RESULTS: Wound healing was complete within 7 days after erbium:YAG laser and two weeks after dermabrasion. Areas treated with BTXA alone also showed complete remission within two weeks. During a follow-up, no relapse occurred with either treatment. CONCLUSION: BTXA is capable of inducing remissions of Hailey-Hailey disease without abrasion for at least 12 months. Among ablative treatments, erbium: YAG laser therapy leads to a more rapid wound closure than dermabrasion, with both causing complete remissions.     

How not to study spontaneous activity

Brains are restless. We have long known of the existence of a great deal of uninterrupted brain activity that maintains the body in a stable state — from an evolutionary standpoint one of the brain's most ancient tasks. But intrinsic, ongoing activity is not limited to subcortical, life-maintaining structures; cortex, too, is remarkably active even in the absence of a sensory stimulus or a specific behavioral task. This is evident both in its enormous energy consumption at rest and in the large, spontaneous but coherent fluctuations of neural activity that spread across different areas. Not surprisingly, a growing number of electrophysiological and functional magnetic resonance imaging (fMRI) studies are appearing that report on various aspects of the brain's spontaneous activity or “default mode” of operation.One recent study reports results from simultaneously combined electrophysiological and fMRI measurements in the monkey visual cortex (Shmuel, A., Leopold, D.A., 2008. Neuronal correlates of spontaneous fluctuations in fMRI signals in monkey visual cortex: implications for functional connectivity at rest. Hum. Brain Mapp. 29, 751–761). The authors claim to be able to demonstrate correlations between slow fluctuations in blood-oxygen-level-dependent (BOLD) signals and concurrent fluctuations in the underlying, locally measured neuronal activity. They even go on to speculate that the fluctuations display wave-like spatiotemporal patterns across cortex. In the present report, however, we re-analyze the data presented in that study and demonstrate that the measurements were not actually taken during rest. Visual cortex was subject to almost imperceptible but physiologically clearly detectable flicker induced by the visual stimulator. An examination of the power spectral density of the neural responses and the neurovascular impulse response function shows that such imperceptible flicker strongly suppresses the slow oscillations and changes the degree of covariance between neural and vascular signals. In addition, a careful analysis of the spatiotemporal patterns demonstrates that no slow waves of activity exist in visual cortex; instead, the presented wave data reflect differences in signal-to-noise ratio at various cortical sites due to local differences in vascularization. In this report, assuming that the term “spontaneous activity” refers to intrinsic physiological processes at the absence of sensory inputs or motor outputs, we discuss the need for careful selection of experimental protocols and of examining the degree to which the activation of sensory areas might influence the cortical or subcortical processes in other brain regions.     

Small intestinal submucosa for reinforcement of colonic anastomosis

Background  Different materials have been evaluated for anastomotic reinforcement to prevent gastrointestinal anastomotic leakage. In this experimental study, small intestinal submucosa (SIS) was tested as a sealing for stapled colonic anastomosis in a porcine model. The aims of this study were to determine the macroscopic and microscopic outcomes and to evaluate the safety and feasibility of applying SIS for anastomotic sealing. Materials and methods  Circular stapled anastomoses were performed in 18 pigs. Standard anastomosis in the control group (n = 8) was compared to an SIS-sealed anastomosis in the study group (n = 10). After 30 days, anastomotic segments were examined for macroscopic and microscopic regeneration and their resistance to mechanical stress. Furthermore, animal survival and clinical course were evaluated. Results  None of the animals developed anastomotic leakage, intraabdominal abscess, or peritonitis. Shrinkage of SIS was evident in nine of ten animals. Encapsulation and displacement of the SIS patches were seen in two animals. Quantity of anastomotic granulation tissue and rate of complete mucosal coverage of anastomotic line were increased in SIS-sealed anastomoses without reaching significance. Moreover, no significant differences were found in the rate of survival of the animals, anastomotic stricture formation, intraabdominal adhesions, anastomotic bursting pressure, and microscopic healing parameters of the anastomosis between stapled colonic standard anastomosis and anastomosis protected by SIS. Conclusion  The results of this study indicate a safe use of SIS for anastomotic reinforcement in a porcine model. Adverse effects like strictures, increased adhesions, and anastomotic abscesses were absent. Promoting effects on colonic wound healing by SIS were microscopically evident. The results argue for a careful clinical evaluation in humans.