Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

Objective

To compare the efficacy of suprapapillary and transpapillary methods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied.

Materials and Methods

Stents were placed in 59 patients. Strictures were categorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared.

Results

Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapapillary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p = 0.37) or method (p = 0.62).

Conclusion

For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.     

Stapled versus hand-sewn vascular anastomoses. An experimental study in the rabbit

OBJECTIVE: Narrowing of vascular anastomoses is a frequently encountered surgical problem, with intimal hyperplasia being one of its most important causes. The aim of the present study was to compare in a rabbit model 'manual' (hand-sewn) with 'stapled' anastomoses (using a staple device) with respect to occurrence and severity of intimal hyperplasia. MATERIALS AND METHODS: Twenty-four male rabbits (mean weight 2,849 g) were randomly allocated to one of two groups (n = 12). An end-to-end anastomosis of the left femoral artery was performed in all animals under general anesthesia. The anastomosis was hand sewn in group 1, while a vascular closure stapler (VCS) was used in group 2. Both anastomotic time and total operation time were recorded. After 28 days, the rabbits were sacrificed. The femoral artery of operated and nonoperated sides were removed and prepared for anatomopathological examination. The I/M ratio (= difference between tunica intima and tunica media) was determined on hematoxylin-eosin stained slides. All results were analyzed using Student's t test. RESULTS: Mean anastomotic times were 25 +/- 7 min for the 'manual' group and 17 +/- 9 min for the 'stapled' group (p = 0.02). There was no significant difference in the total operation time (55 +/- 15 vs. 41 +/- 18 min, p = 0.057). All animals survived the anastomosis procedure. In the group of 'manual' anastomosis, morbidity was significantly higher. At the moment of sacrifice, all anastomoses were patent. There was no difference in the I/M ratio between the groups. CONCLUSIONS: The use of VCS is a promising alternative to hand-sewn anastomoses. It takes less time to perform a stapled anastomosis, the technique has a shorter learning period and morbidity seems to be lower when vascular anastomoses are applied with the VCS in this rabbit model.     

DNA methylation changes measured in pre‐diagnostic peripheral blood samples are associated with smoking and lung cancer risk

DNA methylation changes are associated with cigarette smoking. We used the Illumina Infinium HumanMethylation450 array to determine whether methylation in DNA from pre‐diagnostic, peripheral blood samples is associated with lung cancer risk. We used a case‐control study nested within the EPIC‐Italy cohort and a study within the MCCS cohort as discovery sets (a total of 552 case‐control pairs). We validated the top signals in 429 case‐control pairs from another 3 studies. We identified six CpGs for which hypomethylation was associated with lung cancer risk: cg05575921 in the AHRR gene (p‐value_pooled = 4 × 10^?17), cg03636183 in the F2RL3 gene (p‐value_pooled = 2 × 10 ^{? 13}), cg21566642 and cg05951221 in 2q37.1 (p‐value_pooled = 7 × 10^?16 and 1 × 10^?11 respectively), cg06126421 in 6p21.33 (p‐value_pooled = 2 × 10^?15) and cg23387569 in 12q14.1 (p‐value_pooled = 5 × 10^?7). For cg05951221 and cg23387569 the strength of association was virtually identical in never and current smokers. For all these CpGs except for cg23387569, the methylation levels were different across smoking categories in controls (p‐values_{heterogeneity} ≤ 1.8 x10 ^{? 7}), were lowest for current smokers and increased with time since quitting for former smokers. We observed a gain in discrimination between cases and controls measured by the area under the ROC curve of at least 8% (p‐values ≥ 0.003) in former smokers by adding methylation at the 6 CpGs into risk prediction models including smoking status and number of pack‐years. Our findings provide convincing evidence that smoking and possibly other factors lead to DNA methylation changes measurable in peripheral blood that may improve prediction of lung cancer risk.     

Percutaneous Transhepatic Treatment of Benign Bile Duct Strictures Using Retrievable Covered Stents: Long-Term Outcomes in 148 Patients

ObjectiveTo investigate the long-term outcomes of percutaneous treatment of benign biliary strictures using temporary placement of a retrievable expanded polytetrafluoroethylene (PTFE) covered stent.Materials and MethodsWe retrospectively analyzed the outcomes of 148 patients (84 male and 64 female; age range, 11–92 years) who underwent percutaneous transhepatic placement and removal of a retrievable PTFE-covered stent for the treatment of benign biliary strictures between March 2007 and August 2019 through long-term follow-up. Ninety-two patients had treatment-naïve strictures and 56 had recurrent/refractory strictures.ResultsStent placement was technically successful in all 148 patients. The mean indwelling period of the stent was 2.4 months (median period, 2.3 months; range, 0.2–7.7 months). Stent migration, either early or late, occurred in 28 (18.9%) patients. Clinical success, defined as resolution of stricture after completing stent placement and removal, was achieved in 94.2% (131 of 139 patients). The overall complication rate was 15.5% (23 of 148 patients). During the mean follow-up of 60.2 months (median period, 52.7 months; range, 1.6–146.1 months), 37 patients had a recurrence of clinically significant strictures at 0.5–124.5 months after removal of biliary stent and catheter (median, 16.1 months). The primary patency rates at 1, 3, 5, 7, and 10 years after removal of biliary stent and catheter were 88.2%, 70.0%, 66.2%, 60.5%, and 54.5%, respectively. In the multivariable Cox proportional hazard regression analysis, sex, age, underlying disease, relation to surgery, stricture type, biliary stones, history of previous treatment, and stricture site were not significantly associated with the primary patency.ConclusionLong-term outcomes suggest that percutaneous treatment of benign biliary strictures using temporary placement of retrievable PTFE-covered stents may be a clinically effective method.     

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.     

Effect of intraoperative intravenous ferric derisomaltose supplementation on reduction of postoperative anemia and transfusion in chronic kidney disease patients after total knee replacement

Total knee replacement (TKR) is associated with a large amount of bleeding; therefore, the prevalence of postoperative anemia is high. In particular, patients with chronic kidney disease (CKD) are more vulnerable to postoperative anemia than are healthy individuals. Accordingly, the effect of intraoperative intravenous ferric derisomaltose (FDI) supplementation on postoperative anemia and blood transfusion volume reduction in patients with CKD was studied. Patients who underwent unilateral TKR between January 2019 and December 2020 were retrospectively reviewed. In analyzing the data, the patients fell into the CKD group (n = 85) and the non-CKD group (n = 106). Each group was divided into a group using FDI and a non-FDI group, and classified into 4 groups. The postoperative hemoglobin level for each postoperative day (POD) was determined as the primary outcome. In addition, the patient transfusion rate, volume of transfusion, and length of hospital stay were set as secondary study outcomes during the period from surgery to discharge. There was no statistically significant difference in hemoglobin levels on PODs 0, 1, 2, 7, and 14 in the CKD group. In the CKD group, the transfusion volume of the FDI group was 0.58 ± 0.91 units per person, which was statistically significantly lower than 1.28 ± 1.28 units of the non-FDI group (P = .01). In the CKD group, the transfusion rate of the FDI group was 30.2%, which was statistically significantly lower than that of the non-FDI group, which was 56.3% (P = .02). This study showed that intravenous FDI supplementation after TKR in CKD patients did not reduce postoperative anemia but was an effective and safe treatment to reduce transfusion volume and transfusion rate. There was no statistically significant difference in hemoglobin levels on POD 0, 1, 2, 7, and 14 in the non-CKD group. In the non-CKD group, the transfusion volume of the FDI group was 0.46 ± 0.88 units per person, which was lower than the 0.56 ± 0.91 units of the non-FDI group, but it was not statistically significant (P = .59). In the non-CKD group, the transfusion rate of the FDI group was 23.0%, which was lower than that of the non-FDI group, which was 31.3%, but it was not statistically significant (P = .37).     

The serpentine pattern on MRI as an early prognostic factor after fusion for lumbar spinal stenosis

This study aimed to determine the relationship between the serpentine pattern nerve roots (SNR) and prognosis after lumbar fusion for lumbar spinal stenosis (LSS) by comparing clinical outcomes in patients with or without a serpentine pattern. LSS patients with neurological symptoms often present with SNRs. Several studies have shown that LLS symptoms are worse in patients with SNRs. However, the relationship between SNR and outcome after spinal fusion surgery has not yet been established. A total of 332 patients who underwent spinal fusion surgery between January 1, 2010, and December 31, 2019, were enrolled. Patients were divided into those with a serpentine pattern (S group) and those without a serpentine pattern (N group). The prognosis of the 2 groups was compared using visual analog scale (VAS), Oswestry disability index, claudication distance, medication dose for leg dysesthesia, and glucose tolerance. A total of 113 patients had a serpentine pattern, while the remaining 219 did not. Symptom duration and presence of diabetes mellitus were significantly different between the 2 groups (N = 25.4, S = 32.6, P < .05). Changes in the VAS score for lower extremity pain between the 2 groups at 1 year after surgery showed that patients without a serpentine pattern had significantly better outcomes than those with a serpentine pattern (N: 2.7 ± 1.1 vs S: 4.1 ± 1.3; P < .001), despite the score change at 1 month showing no difference (N: 3.5 ± 0.9 vs S: 3.8 ± 1.0; P = .09). SNRs on MRI are more prevalent in diabetic patients and are a negative prognostic factor in lumbar fusion surgery for LSS. Our insights may help physicians decide the optimal surgical plan and predict the postoperative prognosis of patients with LSS.     

Biofunctional Layered Double Hydroxide Nanohybrids for Cancer Therapy

Layered double hydroxides (LDHs) with two-dimensional nanostructure are inorganic materials that have attractive advantages such as biocompatibility, facile preparation, and high drug loading capacity for therapeutic bioapplications. Since the intercalation chemistry of DNA molecules into the LDH materials were reported, various LDH nanohybrids have been developed for biomedical drug delivery system. For these reasons, LDHs hybridized with numerous therapeutic agents have a significant role in cancer imaging and therapy with targeting functions. In this review, we summarized the recent advances in the preparation of LDH nanohybrids for cancer therapeutic strategies including gene therapy, chemotherapy, immunotherapy, and combination therapy.