Diagnostic impact of 18F-FDG PET–CT evaluating solid pancreatic lesions versus endosonography, endoscopic retrograde cholangio-pancreatography with intraductal ultrasonography and abdominal ultrasound

Purpose  This prospective single-centre phase II trial assessed the diagnostic impact of ¹⁸F-FDG PET–CT in the evaluation of solid pancreatic lesions (∅ ≥10 mm) compared to endosonography (EUS), endoscopic retrograde cholangio-pancreatography (ERCP) with intraductal ultrasound (IDUS), abdominal ultrasound (US) and histopathological reference. Methods  Forty-six patients (32 men/14 women, ∅ 61.7 years) with suspected pancreatic neoplasms underwent PET–CT with contrast-enhanced biphasic multi-detector CT of the upper abdomen followed by a diagnostic work-up with EUS, ERCP with IDUS and US within 3 weeks. PET–CT data sets were analysed by two expert readers in a consensus reading. Histology from surgery, biopsy/fine-needle aspiration and/or clinical follow-up ≥12 months served as standard of reference. Results  Twenty-seven pancreatic malignancies were histopathologically proven; 19 patients had benign diseases: 36/46 lesions (78%) were detected in the head of the pancreas, 7/46 and 3/46 in the body and tail region, respectively. Sensitivity and specificity of PET–CT were 89% and 74%, respectively; positive predictive value (PPV) and negative predictive value (NPV) were 83% and 82%, respectively. Sensitivity (81–89%), specificity (74–88%), PPV (83–90%) and NPV (77–82%) achieved by EUS, ERCP and US were not significantly different. PET analysis revealed significantly higher maximum mean standardised uptake values (SUV_max 6.5 ± 4.6) in patients with pancreatic malignancy (benign lesions: SUV_max 4.2 ± 1.5; p < 0.05). PET–CT revealed cervical lymphonodal metastasis from occult bronchogenic carcinoma and a tubular colon adenoma with intermediate dysplasia on polypectomy, respectively. Conclusions   ¹⁸F-FDG PET–CT achieves a comparably high diagnostic impact evaluating small solid pancreatic lesions versus conventional reference imaging modalities. Additional clinical diagnoses are derived from concomitant whole-body PET–CT imaging. Verena Schick and Christiane Franzius contributed equally to this work.     

Comparison of 1.0 M gadobutrol and 0.5 M gadopentate dimeglumine-enhanced MRI in 471 patients with known or suspected renal lesions: results of a multicenter, single-blind, interindividual, randomized clinical phase III trial

The purpose of this phase III clinical trial was to compare two different extracellular contrast agents, 1.0 M gadobutrol and 0.5 M gadopentate dimeglumine, for magnetic resonance imaging (MRI) in patients with known or suspected focal renal lesions. Using a multicenter, single-blind, interindividual, randomized study design, both contrast agents were compared in a total of 471 patients regarding their diagnostic accuracy, sensitivity, and specificity to correctly classify focal lesions of the kidney. To test for noninferiority the diagnostic accuracy rates for both contrast agents were compared with CT results based on a blinded reading. The average diagnostic accuracy across the three blinded readers (‘average reader’) was 83.7% for gadobutrol and 87.3% for gadopentate dimeglumine. The increase in accuracy from precontrast to combined precontrast and postcontrast MRI was 8.0% for gadobutrol and 6.9% for gadopentate dimeglumine. Sensitivity of the average reader was 85.2% for gadobutrol and 88.7% for gadopentate dimeglumine. Specificity of the average reader was 82.1% for gadobutrol and 86.1% for gadopentate dimeglumine. In conclusion, this study documents evidence for the noninferiority of a single i.v. bolus injection of 1.0 M gadobutrol compared with 0.5 M gadopentate dimeglumine in the diagnostic assessment of renal lesions with CE-MRI.

Minimizing oxidative stress by gene delivery of superoxide dismutase accelerates regeneration after transplantation of reduced-size livers in the rat.

Transplantation of reduced-size livers may lead to a hypermetabolic state and increased production of oxygen radicals. Since oxygen radicals may cause liver injury and impair liver regeneration, we tested the hypothesis that overexpression of superoxide dismutase (SOD) in reduced-size livers (RSL) would accelerate regeneration and reduce injury in a rat model of transplantation of RSL. Donor rats were infected with adenoviruses either expressing SOD1 (Ad.SOD1) or beta-galactosidase (Ad.lacZ). Livers were harvested 72 hours later, reduced to 45% of weight, and transplanted. After transplantation, hepatic SOD activity, graft survival, histopathology, AST/ALT release, and bilirubin were examined. Regeneration was evaluated by BrdU-staining, graft weight, and expression of cyclin D1 and p21. In Ad.SOD1-treated livergrafts, SOD activity increased three-fold compared to controls. Survival was dramatically increased in recipients of Ad.SOD1-RSL (100% vs. 20% in Ad.lacZ-RSL), and peak levels of AST/ALT and bilirubin levels were reduced by 75% and 87.5%, respectively (P < 0.001). In histological sections, hepatocyte necrosis decreased from 24% after Ad.lacZ-treatment to 6% after Ad.SOD1-treatment (P <0.001). Regeneration was also accelerated after Ad.SOD1-treatment as demonstrated by an increase of BrdU-stained cells 24 hours after reperfusion and increased liver weight after 1 week. In conclusion, overexpression of SOD1 in RSL prevents primary non-function of reduced-size liver grafts and accelerates liver regeneration.     

Feasibility study of sutureless distal coronary anastomoses with degradable Y-shunt and tissue adhesives in a porcine off-pump model

The purpose of this study was to examine the feasibility of the combined use of intraluminal biodegradable shunts and surgical adhesives for sutureless distal coronary anastomosis. Eighteen LITA-LAD anastomoses were created in a porcine beating heart model. In group I (n=9) a custom-made silicone Y-shunt provided internal stability, while three different adhesives, N-butyl-2-cyanoacrylate-glue (CYAC); albumin-glutaraldehyde-glue (AG); fibrin-glue (FIB), were applied externally. In group II (n=9) biodegradable polydioxanone (PDS) shunts were used. All anastomoses were examined intraoperatively by flow measurement, blood leakage was quantified and physical strength was tested. In all pigs anastomoses could be created successfully at first attempt, but anastomotic leaks requiring additional sutures occurred in 6 animals. LITA-flow significantly decreased in both groups. A patency rate of 89.9% (8/9) was found in group I while it was 66.6% (5/9) in group II. The lowest amount of blood-loss was measured when CYAC adhesive was used while tensile strength was lowest in the FIB-anastomoses. Preliminarily we could demonstrate the feasibility of performing sutureless distal coronary anastomosis by means of a combination of adhesives and temporary intraluminal shunts. PDS-shunts, however, resulted in a high graft-occlusion rate, so that potentially less thrombotic materials need to be investigated.     

Fokus Neurochirurgische Intensivmedizin 2021/2022

Die Anaesthesiologie -     

Mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve lobectomy in patients younger and older than 70 years

Retrospective single institution analysis of all patients undergoing sleeve lobectomy or pneumonectomy between 2000 and 2005. Seventy-eight patients underwent pneumonectomy (65 patients <70 years, 13 patients >70 years) and 69 sleeve lobectomy (50 patients <70 years, 19 patients >70 years). Pre-existing co-morbidity, surgical indication and induction therapy was similarly distributed between treatment by age-groups. In patients <70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 3% vs. 0 and an overall complication rate of 26% vs. 44%, respectively. In patients >70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 15% vs. 0 and an overall complication rate of 23% vs. 32%. In both age groups, pneumonectomy was associated with more airway complications (NS) and a significantly higher postoperative loss of FEV(1) than sleeve lobectomy (P<0.0001, P<0.03). Age per se did not influence the loss of FEV(1) and DLCO for a given type of resection. Sleeve lobectomy may have a therapeutic advantage over pneumonectomy in the postoperative course of elderly patients.     

Thulium:yttrium‐aluminium‐garnet laser prostatectomy in men with refractory urinary retention

OBJECTIVE

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

PATIENTS AND METHODS

Preoperative data and postoperative outcome, as well as complications, were recorded in 65 patients with a history of recurrent urinary retention before surgery (group A), who were compared with a group of 143 men with no recurrent urinary retention (group B).

RESULTS

The mean (sd ) volume of the prostate was 45.6 (22.5) and 43.1 (24.5) mL in groups A and B, respectively. The respective preoperative prostate‐specific antigen levels were 3.6 (7.8) and 2.8 (6.4) ng/mL, the surgical duration 72.4 (28.9) and 65.6 (28.6) min, the mean laser time and energy 32.5 (11.8) min/140.7 (42.1) kJ and 29.4 (11.6) min/117.6 (11.6) kJ, the maximum urinary flow rate after surgery 19.6 (11.2) and 19.1 (9.6) mL/s, and the postvoid residual urine volume 26.7 (36.3) and 20.6 (27.3) mL. Recorded complications were: bleeding, at 3% in group A and 1.4% in group B; urinary tract infection 15.4% and 4.2%; and a second procedure, 3% and 2.3%. Overall, complications were more frequent in group A (P = 0.02).

CONCLUSION

Thulium:YAG prostatectomy is feasible and effective, even in patients with potentially impaired detrusor function. The long‐term durability of these promising results has yet to be confirmed.     

Emotional context enhances auditory novelty processing in superior temporal gyrus

Visualizing emotionally loaded pictures intensifies peripheral reflexes toward sudden auditory stimuli, suggesting that the emotional context may potentiate responses elicited by novel events in the acoustic environment. However, psychophysiological results have reported that attentional resources available to sounds become depleted, as attention allocation to emotional pictures increases. These findings have raised the challenging question of whether an emotional context actually enhances or attenuates auditory novelty processing at a central level in the brain. To solve this issue, we used functional magnetic resonance imaging to first identify brain activations induced by novel sounds (NOV) when participants made a color decision on visual stimuli containing both negative (NEG) and neutral (NEU) facial expressions. We then measured modulation of these auditory responses by the emotional load of the task. Contrary to what was assumed, activation induced by NOV in superior temporal gyrus (STG) was enhanced when subjects responded to faces with a NEG emotional expression compared with NEU ones. Accordingly, NOV yielded stronger behavioral disruption on subjects' performance in the NEG context. These results demonstrate that the emotional context modulates the excitability of auditory and possibly multimodal novelty cerebral regions, enhancing acoustic novelty processing in a potentially harming environment.     

Total knee arthroplasty using cementless keels and cemented tibial trays: 10-year results

The problem of early mechanical stability of cemented and cementless keels of the tibial component in total knee arthroplasty (TKA) is controversial. The purpose of this study was to assess clinical and radiographic outcomes of a cohort of 51 TKAs using a cemented platform with cementless keel fixation. At a mean follow-up of 10.4 years (range, 7 to 14 years), the mean Knee Society Score (KSS) was 93 points (range, 59 to 100 points), and the mean functional score was 73 points (range, 0 to 100 points). Only one patient demonstrated progressive tibial radiolucencies at 13.1 years follow-up, which resolved with a revision with an exchange of components. The results of this study suggest that a proximally cemented tibial tray with a press-fit keel TKA provides excellent mean 10-year outcomes.

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Résumé  Le problème de la stabilité précoce immédiate de la quille du composant tibial d’une prothèse totale du genou est sujet à controverse. Le propos de cette étude est d’étudier le devenir clinique et radiographique d’une cohorte de 51 prothèses totales du genou, avec un plateau cimenté sans fixation cimentée de la quille. Après un suivi moyen de 10,4 ans (de 7 à 14 ans), le score de la Knee Society a été de 93 points (59 à 100 points) et le score fonctionnel moyen de 73 points (de 0 à 100 points). Seulement un patient a présenté un liseré tibial progressif 13,1 ans après l’intervention avec une nécessité de révision et de changement prothétique. Le résultat de cette étude permet de penser qu’un plateau tibial cimenté avec une quille en press-fit permet d’obtenir de bons résultats avec au moins 10 ans de recul.

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Two of the authors (FRK and MAM) received financial support from Stryker Orthopaedics, Mahwah, New Jersey.

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Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

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The authors FRK and MAM contributed equally to this work.     

Effects of unisegmental disc compression on adjacent segments: an in vivo animal model

It is controversial whether fusion of discs in the spine leads to increased degeneration on the remaining discs or whether the degenerative changes are merely a part of the inevitable natural history process. To determine the effects of unisegmental compression and subsequent recovery on adjacent segments, we studied histology, radiology and intradiscal pressure using an in vivo rabbit model. Fifteen New Zealand rabbits were divided in to three groups of five. In the first group, the intervertebral disc L4–L5 of the lumbar spine was axially loaded for 28 days with an external loading device. In the second group, the intervertebral disc was compressed for 28 days and allowed to recover for an equal amount of time, with the loading device removed. Five animals underwent a sham operation, in which the external loading device was situated, but their discs remained unloaded for 28 days. The intradiscal pressure was determined in the loaded discs as well as in the cranial and caudal adjacent discs. Lateral radiographs were taken from each subjected intervertebral disc with adjacent vertebral bodies and the cranial and caudal adjacent segments. The compressed discs showed lower intradiscal pressure in comparison with the control group, which remained unloaded. In the cranial and caudal discs adjacent to the loaded discs the average intradiscal pressure was similar to the unloaded controls. The loaded discs demonstrated a significant decrease in disc space. No discs adjacent to the loaded discs changed in height. The lamellar architecture of the inner, middle, and outer annulus became more disorganized in the loaded discs. The nucleus pulposus showed increase of mucoid degeneration and increased cell death. Intervertebral discs from the control group and the adjacent discs to the compressed discs maintained their normal morphology. This study shows that mechanical loading of discs in the spine can cause rapid degeneration. Adjacent discs, however, did not change in terms of radiology, intradiscal pressure, or histology.